Every finding on record at Chariton Park Health Care Center

Based on interview and record review, the facility failed to provide adequate supervision for one resident (Resident #88), who was under guardianship, resided on a locked behavior unit, and had a history of elopement and polysubstance abuse, in a review of 30 residents, to ensure the resident did not leave the facility without staff's knowledge. Staff identified the resident was at risk for elopement. Staff reported they were to conduct 15-minute checks, and the resident's care plan identified staff were to ensure the resident was in view when outside in the courtyard. Staff did not consistently document 15 minute checks were completed. On 2/13/26, a resident notified staff he/she observed Resident #88 leave the facility through the plexiglass window in his/her room, hopped the fence, got into a car with someone in the parking lot, then came back in the same way he/she went out. Staff placed the resident on one-on-one supervision following the incident and then placed the resident on 15 minute face checks. On 04/24/26, while in the locked behavioral unit courtyard, the resident climbed onto the facility's roof and over a fence without being seen by staff. Staff outside the courtyard observed the resident leave the facility in a sports utility vehicle that was waiting for the resident. The resident reported he/she left the facility to buy drugs for other residents. The resident told police he/she had been selling methamphetamine (illegal drug) inside the facility. Resident #41 reported he/she purchased illegal drugs from Resident #88 while in the facility. Resident #88 reported he/she left the facility without staff's knowledge multiple times prior to 04/24/26 to purchase drugs for other residents. The facility also failed to secure hazardous chemicals in a storage room on the 400 hall (a secured behavioral health unit) to ensure residents did not have access to the chemicals. The facility census was 116.The administrator was notified of the Immediate Jeopardy (IJ) on 04/26/26 at 5:00 P.M. which began on 04/24/26. The IJ was removed on 04/28/26 as confirmed by the surveyor onsite verification. Review of the facility policy, Elopement and Wandering Residents, dated 06/12/24, showed the following:-The facility ensures residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk;-Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so;-The facility is equipped with door locks/alarms to help avoid elopements;-Alarms are not a replacement for necessary supervision;-The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment or risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary;-Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the care interdisciplinary care plan team;-The interdisciplinary team will evaluate the unique factors contributing to risk to develop a person-centered care plan;-Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff;-Adequate supervision will be provided to help prevent accidents or elopements;-Charge nurses and unit managers will monitor the implementation of interventions, response to interventions and document accordingly;-The effectiveness of interventions will be evaluated and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff;-Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol;-Code [NAME] for elopement from the facility;-Following an elopement, a nurse will perform a physical assessment, document and report findings to the physician;-A social service designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults;-The resident and family/authorized representative will be included in the plan of care;-Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior;-Documentation in the medical record will include findings from nursing and social service assessments, physician/family notification, care plan discussions and consultant notes as applicable. Review of the facility policy, Intensive Monitoring, dated 04/30/24, showed the following:-The purpose was to ensure a system for residents who required increased monitoring for crisis, behavioral, or psychiatric issues;-Intensive monitoring is defined as periodic checks by a facility staff member; intensive monitoring based on the crisis, behavioral, psychiatric issues. The level of monitoring shall be identified by the specific situation or resident assessment;-Residents who show poor impulse control, such elopement ideations, may be placed on intensive monitoring or one-on-one or two-to one (within eyesight of staff) monitoring at the discretion of the administrative staff or supervisor;-The facility's Interdisciplinary Team (IDT) will address the resident's behavioral concerns and ensure interventions are in place to address the resident's needs (psychiatry follow up, counseling, medical needs);-Once the resident has stabilized and/or returned to prior level of function, the facility's interdisciplinary team (IDT) will meet to discuss determination of discontinuation of intensive monitoring;-The facility staff will document the intensive monitoring in the resident's electronic medical record. 1. Review of Resident #1's Preadmission Screening and Resident Review (PASRR, a screening tool used to ensure appropriate placement of persons known or suspected of having a mental impairment, serious mental illness and/or intellectual disability/developmental disability), dated 08/26/25, showed the following:-Diagnoses of bipolar disorder (mood disorder that can cause intense mood swings), schizoaffective disorder (mental health condition that includes features of both schizophrenia and a mood disorder), post-traumatic stress disorder (PTSD, mental health condition triggered by experiencing or witnessing terrifying events), antisocial personality disorder (mental health condition characterized by a lack of regard or remorse for others), psychosis (mental health condition characterized by a disconnection from reality), generalized, and substance abuse;-History of severe polysubstance abuse. The individual's limitations include limited insight, poor judgment and ongoing behavioral concerns (aggression, sexually inappropriate); -The resident needed support and services. Provide environmental support to prevent elopement. Assess and plan for the level of supervision required to prevent harm to self or others. Provide for individual personal space. Establish consistent routines, providing a schedule of daily tasks and activities. Review of the resident's care plan, dated 04/25/25, showed the following:-Special instructions included high elopement risk. May be outside in smoke area 15 minutes at a time by himself/herself. Must be in view and not past 600 hall. May have no visitors at the facility unless it is guardian approved. -The resident was at risk for elopement due to a history of elopement from a prior secure facility. The resident will be monitored closely, remain safe and will not elope from facility. The facility will complete an elopement risk assessment on admission, readmission and quarterly. Face checks/intensive monitoring will be completed per facility protocol. The resident will not go into courtyard without staff supervision. Review of the resident's elopement risk evaluation, dated 02/11/26, showed the following:-History of elopement or an attempted elopement while at home;-History of elopement or attempts to leave the facility without informing staff;-The resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door;-The resident's wandering behavior is a pattern, goal-directed, aimlessly and non-goal directed, likely to affect the safety or well-being of self/others and the privacy of others;-Score of seven, indicating the resident was at risk of elopement (score of one or higher indicated risk of elopement). Review of the resident's nurses' notes, dated 02/13/26, showed at 11:00 P.M., a resident notified the team lead that Resident #88 went out the plexiglass window, hopped the fence, got into a car with someone, sat in the parking lot, then came back in the same way he/she went out. The team leader alerted the nurse. Staff searched the resident's room and discovered the screen was missing out of the left window, but the window was intact. When they tried to close the left window, they noticed the top left of the middle window looked like it was poking out. When the staff member poked at the window to see if it was still attached, the plexiglass window fell out. There was evidence of wood shavings and paint shavings on the inside of the windowsill. The resident said he/she did not go anywhere, and a hurricane broke the window. Staff placed the resident on one-on-one for safety. Maintenance staff boarded up the window until they could fix it properly. During an interview on 04/27/26, at 10:34 A.M., the Staffing Coordinator said he fixed the window in the resident's room in February. It looked like the resident moved the window repeatedly until the glass popped out. Review of the resident's care plan, dated 02/13/26, showed the following:-Special instructions included high elopement risk. May be outside in smoke area 15 minutes at a time by himself/herself. The resident must be in view and not past the 600 hall. May have no visitors at the facility unless it is guardian approved. -The resident was at risk for elopement due to a history of elopement from a prior secure facility. The resident will be monitored closely, remain safe and will not elope from facility. The facility will complete an elopement risk assessment on admission, readmission and quarterly. Face checks/intensive monitoring will be completed per facility protocol. The resident will not go into courtyard without staff supervision. One-on-one for protective oversight unless agitates resident. Educate residents about not leaving the facility, not tampering with facility property and covenant guidelines. Educate staff on elopement risk, face checks, monitoring lighters, checking residents when returning from leave of absence and management notification. Review of the resident's elopement risk evaluation, dated 02/14/26, showed the following:-History of elopement or attempts to leave the facility without informing staff;-The resident wanders;-Score of two, indicating the resident was at risk of elopement (score of one or higher indicated risk of elopement). Review of the resident's nurses notes, dated 02/17/26, showed staff documented the following:-At 3:46 A.M., the resident remains on 15-minute checks for protective oversight;-At 5:33 P.M., the resident was on 15-minute checks. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 04/18/26, showed the following:-Cognitively intact;-No impaired mobility and required no assistive device. -No wandering behaviors. Review of the resident's monitoring task documentation, dated 4/14/26 through 4/24/26, showed the following:-The resident was on 15-minute face checks during the day and every hour face checks during hours of sleep (HS);-On 4/14/26, staff documented a face check on 1:51 A.M. and not again until 4:34 A.M. (2 hours and 43 minutes between checks) and at 6:29 A.M. (1 hour and 55 minutes between checks);-On 4/14/26, staff documented a face check at 12:05 P.M. and not again until 2:04 P.M. (1 hour and 59 minutes between checks) and again at 3:10 P.M. (1 hour and 6 minutes between checks);-On 4/14/26, staff documented a face check at 4:55 P.M. and not again until 6:15 P.M. (1 hour and 20 minute between checks) and then again at 8:18 P.M. (2 hours and 3 minutes since the last check); -On 4/15/26, staff documented a face check at 12:14 A.M. and not again until 2:24 A.M. (2 hours and 10 minutes between checks) and not again until 5:01 A.M. (2 hours and 37 minutes between checks);-On 4/15/26, staff documented a face check at 6:27 A.M. and not again until 11:01 A.M. (4 hour and 34 minutes between checks);-On 4/15/26, staff documented a face check at 11:42 A.M. and not again until 1:59 P.M. (2 hours and 17 minutes between checks);-On 4/15/26, staff documented a face check at 2:00 P.M. and not again until 4:46 P.M. (2 hours and 46 minutes between checks);-On 4/15/26, staff documented a face check at 6:11 P.M. and not again until 8:27 P.M. (2 hours and 16 minutes between checks);-On 4/15/26, staff documented a face check at 8:53 P.M. and not again until 10:23 P.M. (1 hour and 30 minutes between checks);-On 4/16/26, staff documented a face check at 1:41 A.M. and not again until 3:23 A.M. (1 hour and42 minutes between checks);-On 4/16/26, staff documented a face check at 6:17 A.M. and not again until 12:35 P.M. (5 hours and 18 minutes between checks);-On 4/16/26, staff documented a face check at 1:01 P.M. and not again until 2:49 P.M. (1 hour and 48 minutes between checks);-On 4/17/26, staff documented a face check at 12:29 A.M. and not again until 2:15 A.M. (1 hour and 46 minutes between checks);-On 4/17/26, staff documented a face check at 7:36 A.M. and not again until 9:43 A.M. (2 hours and 7 minutes between checks);-On 4/17/26, staff documented a face check at 3:45 A.M. and not again until 6:22 P.M. (2 hours and 37 minutes between checks);-On 4/18/26, staff documented a face check at 2:26 A.M. and not again until 5:08 A.M. (2 hours and 42 minutes between checks);-On 4/18/26, staff documented a face check at 4:40 P.M. and not again until 6:17 A.M. (1 hour and 37 minutes between checks);-On 4/19/26, staff documented a face check at 12:05 A.M. and not again until 2:54 A.M. (2 hours and 49 minutes between checks);-On 4/21/26, staff documented a face check at 12:20 P.M. and not again until 2:08 P.M. (1 hour and 48 minutes between checks);-On 4/22/26, staff documented a face check at 10:43 A.M. and not again until 12:03 P.M. (1 hour and 20 minutes between checks) and not again until 1:28 P.M. (1 hour and 35 minutes between checks);-On 4/22/26, staff documented a face check at 6:47 P.M. and not again until 8:12 P.M. (1 hour and 25 minutes between checks);-On 4/23/26, staff documented a face check at 1:00 A.M. and not again until 3:34 A.M. (2 hours and 34 minutes between checks);-On 4/23/26, staff documented a face check at 7:20 A.M. and not again until 9:08 A.M. (1 hour and 48 minutes between checks);-On 4/23/26, staff documented a face check at 6:07 P.M. and not again until 8:07 P.M. (2 hours between checks). Review of the resident's nurses note, dated 04/23/26 at 5:29 P.M., showed staff documented the resident was on 15-minute checks. Review of the resident's 15-minute face check documentation (located in the resident's electronic medical record), dated 04/24/26, showed staff documented the resident was in the building at 1:01 A.M., 4:28 A.M., 6:24 A.M., 7:42 A.M., 9:24 A.M., 10:19 A.M. and 10:44 A.M. (Review showed no documentation staff conducted any other face checks for the resident on 4/24/26 prior to 3:44 P.M.) Review of the residents' nurses' notes, dated 04/24/26, showed staff documented the following:-At 11:45 A.M., the resident got in a car out of the building. Staff called a Code [NAME] immediately and searched Station Two for the resident in every room, closet, under bed and all staff areas and outside. The resident was not found. Staff went out into the community to search for the resident. Staff notified the police of the missing resident with description;-At 1:30 P.M., staff located the resident at his/her friend's house. The resident willingly got in the car with the Activity Director and certified medication technician (CMT);-At 2:05 P.M., the resident returned to the facility. Staff searched the resident and did not find any illicit substances (illegal drugs). The resident said he/she did not bring any (illicit substances) back nor did he/she take any while out. He/She said he/she should never have left and felt depressed at this time. The resident said he/she wants to cure his/her family member's cancer and was headed to Honduras. The resident said he/she received money from peers to bring back drugs, but instead he/she was going to Honduras. The resident continues to say he/she did not take drugs or bring them back. During an interview on 04/27/26 at 9:15 A.M., Resident #42 the following:-He/She was outside (in the fenced courtyard) on 04/24/26 playing basketball and smoking a cigarette around 11:30 A.M;-He/She saw Resident #88 scale the wall, climb onto the roof and go over the fence. During an interview on 04/27/26, at 10:34 A.M., the Staffing Coordinator said the following:-He was standing outside in the parking lot (on 04/24/26) and saw an SUV pull up to the facility. Someone with Resident #88's build jumped into the SUV;-The SUV was an older black SUV with decals, like angel wings, on the back;-He had seen the same SUV drive in the facility's parking lot before. During an interview on 04/26/26, at 1:20 P.M., the resident said the following:-He/She left the faciity on [DATE] because he/she was trying to get enough money to go to Honduras;-He/She scales the fence. He/She is in shape and can pull him/herself up and over most things;-Other residents give him/her money and he/she leaves the building to get drugs. He/She has made four or five runs (out of the facility) to get drugs, but staff caught him/her on 04/24/26. He/She shouldn't have tried to leave in the middle of a weekday. Usually, he/she jumped the fence and was back to the facility within an hour. He/She called people to take him/her to get the drugs. Sometimes, the people he/she called brought drugs to him/her. He/She went to their vehicle and then came back into the facility. He/She purchased the drugs with money he/she received from other residents;-He/She called friends he/she met when in another facility to pick him/her up on 04/24/26;-He/She went with them to their home in another town (approximately 20 miles away); -He/She cannot tell if he/she took anything or not; that would make it worse for him/her;-He/She had $200 when he/she left the facility but did not have money or drugs when he/she arrived back at the facility. During interviews on 04/26/26 and 04/29/26 at 8:58 A.M. and 11:44 A.M., CMT B said the following: -Resident #88 had special instructions on the care plan before the elopement that he/she could be outside unsupervised for 15 minutes;-He/She worked on Station Two where Resident #88 resides;-On 04/24/26, he/she was the Team Lead (TL) or staff member in charge on Station Two;-On 04/24/26, he/she saw the resident on the unit in the dining room around 11:30 A.M.;-He/She left the facility, and when he/she returned, staff told him/her someone saw the resident get into an older black SUV with white decals on the back;-He/She and the Activity Director searched for the resident in his/her personal vehicle and saw the black SUV leaving town; -They followed the vehicle to a residence in another town approximately 20 minutes away from the facility;-The resident was cooperative and got in the car with them; -The resident had purple discoloration on the back of both of his/her arm. The resident complained of cotton mouth, and his/her eyes were dilated;-The resident looked high (under the influence), but never admitted to using any substances;-He/She heard the resident went over the fence, got in a car and came back in once a couple of months ago but no other times. During an interview on 04/26/26, at 4:25 P.M., the Activity Director said the following;-The Staffing Coordinator saw Resident #88 get into a black SUV in the facility's parking lot;-The staff called a Code [NAME] (missing person); staff could not find the resident;-She and CMT B looked for the resident in the community;-They saw an SUV that matched the description from the Staffing Coordinator, headed out of town;-They lost the vehicle, so they called back to the facility;-When the resident was in another facility (in the same town where staff found the resident), some staff were friendly with the resident;-They got the address of one of the people who was close to the resident;-She and CMT B drove around those neighborhoods, and they saw an SUV matching the description; -She and CMT B saw Resident #88 walking to the vehicle with two people;-The resident said he had $200 on him/her when he/she left, but did not have the money now;-The resident got into the car with them and they returned to the facility. Review of the Police department report, dated 04/24/26 at 11:58 A.M., showed on 04/24/26 at approximately 11:58 P.M., Police Officer J responded to the facility for a reported missing person. Police Officer J arrived on scene and spoke to a staff member who observed the resident getting into the back seat of an unknown black SUV at approximately 11:35 P.M. After staff looked for the resident for approximately 25 minutes, the police were notified and reported the resident missing. Police Officer J was told the resident told other residents he/she was going to get drugs. Police Officer J went to the last known location of the resident which was a grassy enclosed area behind the facility. Police Officer J observed ductwork with a large dent on the top and above it, saw a gutter which appeared to be loose and had a large, loose nail falling out. Police Officer J, while standing on the ground with flat feet, could easily reach the gutter at that spot. It is possible for a resident in good physical condition to hoist themselves up on the roof by themselves, or with the aid of another resident. The administrator said the resident has escaped before and is always located in the same town approximately 20 miles away. Later the same day, a staff member located the resident in a residential area in the town 20 miles away. The resident was secured in the staff member's vehicle and brought back to the facility. Staff searched the resident before going into the facility. The resident told Police Officer J he/she had been selling methamphetamine inside the facility so he/she could acquire enough funds to go to Honduras and cure cancer. Call closed at 02:41 P.M. During an interview on 04/27/16 at 01:16 P.M., Police Officer J said the following:-Staff reported a staff member saw the resident get in the back seat of a black SUV in the facility parking lot at 11:35 P.M.;-Staff reported the resident was outside before leaving the facility property without staff supervision;-After the facility identified the resident was missing, staff looked for the resident for 20-30 minutes before reporting to the police;-A staff member drove through a residential area in another town, saw the resident, and picked him/her up;-The resident returned to the facility approximately at 2:30 P.M.;-He/She was still at the facility when the resident returned;-The resident said he/she told another resident he/she was getting dope (slang for drugs);-The resident said he/she was selling dope in the facility to get enough money to go to Honduras to cure cancer. During an interview on 04/26/26, 4/27/26 and 04/30/26, at 5:27 P.M., 12:21 P.M. and 3:00 P.M., the Administrator said the following:-The resident had a history of elopement in his/her previous facility;-At the previous facility the resident used a chair and climbed on the roof;-Staff were aware of the resident's elopement history; -The resident had been working the program and was doing well and was allowed to go outside unsupervised;-The resident's care plan had an intervention of one-on-one for protective oversight in the past, but the resident had not been on one-on-one for some time;-If a resident had a known history of elopement, staff should supervise them when outside; -The resident eloped from the facility on 04/24/26 right after the 11:00 A.M. smoke break;-The Staffing Coordinator was outside and saw someone matching Resident #88's build run and get into a black SUV;-Staff called a Code [NAME] and searched for the resident in the building and in the community;-When the resident eloped from the previous facility, he/she was found with the previous facility's employees;-She sent staff to drive through the areas in the town where the individuals (from the previous facility) resided; -Facility staff spotted the resident carrying a speaker and walking with two people to the black SUV;-The facility staff returned the resident to the facility;-The resident was gone less than two hours and was back at the facility around 1:30 P.M.;-When the resident returned to the facility, he/she said he/she was trying to go to Honduras to help his/her family member;-The resident said he/she did not take any illicit drugs while he/she was out. The facility did not drug test the resident. She did not feel the resident was impaired. During an interview on 04/26/26, at 11:08 A.M., Resident #23 said the following:-Resident #88 eloped from the facility on 04/24/26;-When Resident #88 returned, he/she was high and was stumbling and slurring his/her words. During an interview on 04/26/26, at 11:19 A.M., Resident #6 said the following:-Resident #88 eloped the facility on 04/24/26;-When Resident #88 came back, he/she was strung out;-Resident #88 couldn't even hold a conversation when he/she returned and his/her pupils were dilated. During an interview on 04/27/26 at 9:38 A.M., Resident #41 said the following:- Runners sneak out of the facility by going over the fence and bring drugs back into the facility;-The residents coordinate drug deals on their cell phones. Resident #88 coordinated a drug deal last Friday (04/24/26).-He/She saw Resident #88 get onto the roof and climb over the fence on 04/24/26;-He/She took methamphetamines and cocaine while in the facility; -He/She purchased drugs in the facility from Resident #88;-He/She would not confirm what drugs he/she purchased from Resident #88;-Other residents bring drugs back when going out of the facility on pass;-The residents give whoever is going to get the drugs money before the resident leaves and then gets drugs when the resident returns to the facility;-Residents can get any drugs they want in this facility, such as cocaine, crack, meth, Xanax and Adderall. During an interview on 04/28/26 at 9:52 A.M., CMT A said the following:-He/She worked 04/24/26 on Station Two when Resident #88 eloped;-He/She was in another resident's room providing care;-Staff should supervise any resident at risk for elopement, including Resident #88, when they were outside;-He/She did not know if staff were in the courtyard when the resident eloped on 04/24/26. During an interview on 04/27/26 at 07:38P.M., Staffing/Mentor/Educator said the following:-The resident eloped on 04/24/26;-The resident was on 15-minute checks before he/she eloped on 04/24/26. During an interview on 04/30/26 at 04:18 P.M., the resident's guardian said the following:-The facility notified him/her of Resident #88's elopement on 04/24/26;-The Administrator said the resident got into a car around 11:30 A.M. and left the facility;-The SSD notified his/her office when the resident returned to the facility;-The SSD said the resident was located in a residential area, and the resident said he/she was trying to buy meth (an illegal drug). 2. Review of the facility policy, Chemical Storage and Labeling, dated 02/02/24, showed the following:-To ensure all chemicals are stored safely:-Chemicals must be stored in a vented room;-The chemical storage room must remain locked at all times when someone is not in the storage room;-Only the Housekeeping/Environmental Services Manager and his/her designee will have access to the chemical room. Observation on 04/26/26 at 10:50 A.M., showed the following:-The door to the storage room on the 400 hall (located in a locked unit) was not closed and locked and stood open 2 inches;-Four unidentified residents walked back and forth in the hallway past the room;-No staff were on the hall or site of the storage room;-Observation inside the storage room showed: -Seven bottles of Acid Bowl Cleaner (Royal); -Three bottles of Restroom Disinfectant (SparCling); -Seventeen containers of Comet Deodorizing Cleaner; -Five large bottles of Heavy-Duty Degreaser and Cleaner Concentrate (All-Pro); -Spray bottle with Peroxy handwritten on the bottle; -Spray bottle with Peroxy 4 D handwritten on the bottle; -Five one-gallon bottles of Enzyme Floor Cleaner (Sure Step); -One large spray bottle of Coffee and Tea Carafate Cleaner (SparClean); -Three one-gallon Delimer (SparClean); -Five one-gallon bottles Silverware Pre-Soak (SparClean); -Six one-gallon bottles Clean by 4D; -Two five-gallon buckets of Low Temperature Rinse Aid (SparClean); -One five-gallon bucket of LIQ Nature's Way (Natural Digestant for Municipal and Industrial Wastewater Treatment, Consume); -One five-gallon bucket of Pot and Pan Detergent (SparClean); -One five-gallon bucket of Metal Safe Machine Dish Detergent (SparClean); -Two five-gallon bucket of Low Temperature Dish Machine Detergent (SuperSmart). Observation 04/26/26 at 2:33 P.M., showed the door to the storage room on the 400 hall was not latched into the door frame and was able to be opened freely. The storage room contained bottles and buckets of chemicals as observed on 04/26/26 at 10:50 A.M. Two unidentified residents walked up and down the 400 hall. No staff were present on the hall. Review of the Material Safety Data Sheet (MSDS) for Royal Acid Bowl Cleanser showed the following:-Hazards Identification: -Signal Word: DANGER; -Hazards: Corrosive to metals, causes severe skin burns and serious eye damage; -Inhalation: Harmful if inhaled; may cause damage to respiratory tract; -Ingestion: Harmful or fatal if swallowed;-Handling and Storage: keep in a locked area in the original container. Review of the MSDS for SparCling Restroom Disinfectant showed the following:-The product was highly acidic;-Hazards: Contains Hydrochloric Acid, causing severe skin burns and eye damage;-Safety Measures: Harmful if inhaled; -First Aid: If in eyes or on skin, immediately rinse with water and seek medical attention;-Harmful if swallowed - symptoms may cause nausea, vomiting, pain and diarrhea. Review of the MSDS for Comet Deodorizing Cleaner showed the following:-Hazardous by OSHA criteria;-Ingestion may cause gastrointestinal irritation, nausea, vomiting and diarrhea; Review of the MSDS for Heavy-Duty Degreaser and Cleaner Concentrate (All-Pro) showed the following:-Signal word: DANGER; Hazardous;-If swallowed could cause gastric perforation or perforation of the esophagus and stomach;-Store securely, locked up. Review of the MSDS for Peroxy showed the product was hazardous and harmful if swallowed. Review of the MSDS for Peroxy 4 D showed the following:-Combustible liquid;-Harmful if swallowed and causes severe skin burns and eye damage;-Corrosive. Review of the MSDS for Sure Step Enzyme Floor Cleaner showed the product was hazardous and may be harmful if swallowed. Review of the MSDS for SparClean Coffee and Tea Carafate Cleaner showed product was hazardous and may be harmful if swallowed. Review of the MSDS for SparClean Delimer showed the following:-Corrosive; -Danger: harmful if inhaled or swallowed;-Store locked up. Review of the MSDS for Silverware Pre-Soak (SparClean) showed the following:-Causes serious eye irritation and may be harmful if swallowed;-Hazard Category: Acute Toxicity;-Keep it stored locked up. Review of the MSDS for Clean by 4D showed the following:-Product is a combustible liquid;-Can cause serious eye damage, skin irritation and harmful if inhaled or swallowed;-Hazard category: Acute toxicity;-Keep it stored locked up. Review of the MSDS for Low Temperature Rinse Aid (SparClean) showed the following:-Causes eye irritation and may be harmful if swallowed;-Haza[TRUNCATED]

Based on interview and record review, the facility failed to treat one resident (Resident #79), in a review of 30 sampled residents, with dignity and respect when staff did not provide reasonable accommodation with toileting and told the resident to urinate and defecate in his/her bed. The facility census was 85. Review of the facility policy, Promoting/Maintaining Resident Dignity, revised 9/21/25, showed the following:-It is the practice of this facility protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality;-Every resident has a right to be treated with dignity and respect;-All staff will speak to and treat all residents with dignity and respect;-All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights;-The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences;-When interacting with a resident, pay attention to the resident as an individual;-Respond to requests for assistance in a timely manner;-Groom and dress residents according to resident preference. Review of Resident #79's face sheet, showed the following:-admitted on [DATE];-He/She was his/her own responsible party.-Diagnoses included generalized anxiety disorder, major depressive disorder, borderline personality disorder (a mental health condition characterized by pervasive pattern of instability in moods, self-image, behavior and relationships), post-traumatic stress disorder (PTSD) (a mental health condition triggered by experiencing or witnessing terrifying events, causing long-lasting flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the trauma), agoraphobia with panic disorder (an intense fear of situations where escape might be difficult or help unavailable), need for assistance with personal care, and closed (fracture with the skin intact) displaced (out of alignment) intertrochanteric (a fracture of the hip) fracture or right femur. Review of the resident's comprehensive care plan, dated 3/27/26, showed the following:-He/She had an activities of daily living (ADL) self-care performance deficit related to activity intolerance, impaired balance, limited mobility and leg fracture;-He/She was totally dependent on one staff for personal hygiene;-He/She required assistance from one staff for toileting and to move between surfaces;-Provide the resident with as many situations as possible which give the resident control over the resident's environment and care delivery. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/30/26, showed the following:-Cognitively intact;-Dependent on staff for toileting hygiene and personal hygiene;-Dependent on staff for toilet transfers;-Frequently incontinent of bowel and bladder. Review of the resident's orthopedic consult note, dated 4/16/26, showed the following:-Continue therapy as ordered;-Weight bearing as tolerated to the right lower extremity, no restrictions. Observation on 4/26/26 at 2:37 PM showed the following:-Nursing Assistant (NA) E, NA S and NA T transferred the resident from his/her wheelchair to the bed with a hoyer lift (mechanical lift);-After the transfer, the resident told staff he/she would like to use the bathroom;-NA S asked the resident if he/she wanted staff to remove his/her pants so he/she could go, then staff could clean him/her after going;-The resident was visibly uncomfortable with the question and said he/she was uncomfortable with the amount of staff present (three aides, one supervisory staff, and the state agency (SA) staff);-Seeing the resident's discomfort, the SA staff excused themselves from the room. Review of the resident's progress notes, dated 4/26/26 at 4:08 P.M., showed staff transferred the resident to bed with a hoyer lift. The resident refused the bedpan and had a bowel movement in the bed. Staff provided perineal care. During interviews on 4/27/26 at 5:50 P.M. and 4/29/26 at 4:01 P.M., the resident said the following:-He/She no longer used the bedpan because it left an indentation when staff left him/her sitting on it for a long period of time when he/she first arrived at the facility;-Since that time, he/she had a fear of being forgotten when using the bedpan, so staff told him/her to soil himself/herself, then staff cleaned him/her;-Staff never offered a way to transfer him/her to a toilet or commode;-He/She did not like being told to soil himself/herself;-He/She felt embarrassed, dirty, and undignified when staff told him/her to soil himself/herself and to wait for staff to clean him/her. During an interview on 4/30/26 at 4:15 P.M., NA S said the following:-The resident used a hoyer lift to transfer;-Sometimes, the resident refused to use the bedpan because it hurt him/her too much;-He/She did not believe the facility had any hoyer lift pads with openings for residents to use the commode; he/she had never asked;-He/She just made sure the resident took his/her pants off before going (to the bathroom) so the resident wouldn't soil his/her clothes. During an interview on 4/30/26 at 4:21 P.M., Licensed Practical Nurse (LPN) U said the following:-The resident was cleared for weight-bearing as tolerated, but therapy had not released him/her, so he/she was still a hoyer transfer;-He/She believed the facility had a hoyer lift pad with an opening if the resident preferred to use the toilet or commode;-He/She did not believe it was ever acceptable to have a resident soil themselves. Staff should offer every available option. If the resident refused, staff should document the refusal. During an interview on 4/30/26 at 6:03 P.M., the interim Director of Nursing (DON) said the following:-Staff should treat residents with dignity and respect;-Staff should speak to residents as they would like to be spoken to;-Staff should offer a residents the restroom, commode or bedpan, according to their condition;-Staff should not tell residents to soil themselves. During an interview on 4/30/26 at 6:03 P.M. the Administrator said the following:-Staff should treat residents with dignity and respect;-Staff should speak to residents with kind words;-Staff should offer residents the toilet or commode first. If the resident was unable to use these, the bedpan would be an acceptable alternative;-The facility had a hoyer lift pad with a hole that would allow staff to transfer resident to the toilet or commode.

Based on record review and interview, the facility failed to ensure one resident (Resident #4) was free from physical abuse when Resident #3 hit Resident #4 in the head multiple times. The facility also failed to ensure one resident (Resident #7) was free from verbal abuse and intimidation when Residents #3, #5, and #6 entered Resident #7's room and verbally intimidated and threatened to harm Resident #7 if he/she snitched on them for doing drugs and/or bringing drugs into the facility. The facility census was 111. Review of the facility's policy, Abuse and Neglect, dated 06/12/26, showed the following:-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish, which can include resident to resident altercations;-Physical abuse is purposefully beating, striking, wounding, or injuring any resident or in any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner;-Physical abuse includes hitting, slapping, and punching;-Verbal abuse means the use of oral, written or gestured language that willfully includes disparaging derogatory terms to residents or within their hearing distance regardless of their age, ability to comprehend, or disability. This includes using profanity or speaking in a threatening or derogatory manner in a resident's presence. Examples include harassing a resident, insulting, ridiculing, yelling at a resident with the intent to intimidate, and threatening residents. Review of the facility policy, Resident Rights, dated 09/21/25, showed the residents have the right to be free from verbal, sexual, mental, and physical abuse. 1. Review of Resident #4's Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care), dated 04/01/26, showed the following:-The resident's diagnoses included bipolar disorder (mood disorder that can cause intense mood swings), mood disorder, anxiety disorder, oppositional defiant disorder (ODD, frequent and ongoing pattern of anger, irritability and defiance), and schizophrenia;-The resident was verbally threatening;-The resident had significant emotional dysregulation including difficulty managing mood fluctuations, irritability, and anger. He/She had a history of aggression, agitation, and impaired impulse control;-The resident's condition resulted in significant functional impairment. His/Her insight and judgment are limited, and he/she demonstrates impaired decision making capacity;-The resident had serious difficulty interacting appropriately and communicating effectively with other persons. Review of the resident's progress note, dated 05/29/26 at 2:19 P.M., showed Certified Medication Technician (CMT) E documented the resident was appropriate with staff and peers. The resident had no behaviors this shift. (Review showed no documentation related to a resident-to resident physical altercation in the resident's progress notes dated 05/29/26.) Review of the facility Registered Nurse Investigation, dated 05/29/26, showed the following:-Type of incident: Physical aggression not involving the head;-Witnesses: Certified Nurse Assistant (CNA) E, CMT N, Resident #3 and Resident #4;-Investigative note: Resident #4 was in the dining room screaming, hollering, cussing, and said Resident #3 paid somebody to kill him/her. Resident #3 came in the dining room. Residents #3 and #4 started going off on one another. Resident #3 attacked Resident #4, had him/her on the ground and the residents hit each other. Staff intervened and separated the residents. Resident #3 was placed on one-on-one monitoring;-The altercation was not a result of abuse or neglect. The facility did not identify it as abuse; -The altercation was not preventable because in CMT N's interview she said she tried to talk to Resident #4 or get him/her to calm down in their room. CMT N felt that was all she could do at the time; -Staff provided education and intensive monitoring. During an interview on 06/10/26 at 11:13 A.M., the resident said the following:-Resident #3 gave him/her $140 to buy video games for him/her;-Resident #3 told him/her to keep $40 for getting the games while he/she went on pass on 5/27/26;-He/She returned to the facility and gave Resident #3 $40 and no video games;-On 05/29/26, he/she went outside to smoke. Resident #5 was already outside and yelled that he/she (Resident #4) was the type of person to take your money and run. He/She told Resident #5, I should slap the fuck out of you. Resident #5 said he/she and Resident #3 should beat the fuck out of him/her (Resident #4) because he/she (Resident #4) robbed Resident #3;-At this point, staff took him/her back inside the facility and he/she sat at a table in the dining room;-Resident #3 came in the dining room and sat a few tables away from him/her;-He/She confronted Resident #3 because Resident #3 said he/she robbed him/her and Resident #3 was going to pay another resident to beat him/her up;-Resident #3 said he/she was mad Resident #4 took his/her money and did not get a video game. Resident #4 and Resident #3 argued back and forth and then Resident #3 pushed him/her to the floor;-Resident #4 got on his/her knees and grabbed Resident #3's shirt. Resident #3 pinned his/her arms down on the floor and hit him/her (Resident #4) on the side of the head and face;-CMT N separated them and then Resident #3 threw his/her (Resident #4's) phone on the floor and stomped on it;-Resident #4 was sent to the hospital and had x-rays. During an interview on 06/12/26 at 9:27 A.M., CMT N said the following occurred on 05/29/26: -He/She went to the dining room and Resident #4 was screaming and yelling about how Resident #3 wanted to hire someone to beat up him/her;-He/She tried to talk to Resident #4 to calm him/her down or to get him/her to go to his/her room, but Resident #4 would not listen and continued to scream about Resident #3. -Resident #3 came in the dining room and sat a few tables away from Resident #4 and was fine for a few minutes. Resident #4 got up and went towards Resident #3 and they started hitting one another;-He/She immediately separated the residents and called the charge nurse to assess the residents. Review of the resident's Medication Administration Record (MAR), dated 05/29/26, showed the resident received 10 milligrams (mg) olanzapine (antipsychotic) at 3:50 P.M. and 650 mg acetaminophen for a pain level of seven out of 10 at 4:35 P.M. Review of the resident's progress note, dated 05/29/26 at 6:20 P.M., showed Licensed Practical Nurse (LPN) H documented the resident left with emergency medical services to the hospital. Review of the resident's progress note, dated 05/29/26 at 7:28 P.M., showed the following:-LPN I documented Resident #4 had a visit with the psychiatric provider via telehealth after an altercation;-The provider ordered scheduled medication and an as needed medication;-The resident had a hematoma (localized collection of blood caused by an injury to a blood vessel) on the left temple. The resident complained of head pain, blurred vision, and left shoulder pain;-The psychiatric provider ordered staff to send the resident to the hospital for evaluation of the hematoma obtained during the altercation. Review of the resident's hospital records, dated 05/29/26, showed the following: -The resident presented to the hospital with pain in the left side of his/her head above his/her ear and the back of his/her head with a pain level of eight out of 10 (on a scale of zero to 10 with 10 being the most pain). He/She also had left shoulder pain, a headache and blurred vision;-The resident was given intramuscular pain medication;-The resident had x-rays of his/her head, left shoulder, and neck that showed no acute injury or dislocation;-Discharge diagnoses included unspecified injury of head, pain in left shoulder and strain of muscle at the neck. Review of the resident's MAR, dated 05/30/26, showed the resident received 600 milligrams (mg) ibuprofen for a pain level of seven out of 10. Review of the resident's interdisciplinary team (IDT) progress note, dated 06/01/26 at 8:05 A.M. (documented as a late entry) showed the following:-The Social Service Director (SSD) documented the interdisciplinary team (IDT) met with the resident;-The resident said he/she was okay since the physical altercation with a peer;-The resident felt upset his/her phone was broken. IDT told the resident a phone was ordered;-The IDT reminded the resident to talk to staff if he/she had any other issues and the resident said he/she understood. -The resident felt safe at the facility. Review of the resident's MAR, dated 06/01/26, showed the resident received 600 mg ibuprofen for a pain level of six out of 10. During an interview on 6/12/26 at 2:35 P.M., the Regional Nurse said the following:-She investigated the altercation between Residents #3 and #4 and found the root cause was due to the residents trading money for video games;-Staff discouraged the residents from buying, selling, and trading with one another and provided education to the residents;-She did not know Resident #4 had a verbal disagreement outside with Resident #5 before Residents #3 and #4 had a physical altercation. 2. Review of Resident #3's PASRR, dated 11/26/18, showed the following:-The resident's diagnoses included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), psychotic disorder (severe mental disorder that caused abnormal thinking and perceptions), and delusional disorder (serious mental illness where a person experienced one or more persistent fixed false beliefs);-The resident had occasional physical aggression toward staff and peers;-The resident did not make good decisions, destroyed property, and was verbally abusive and threatening;-The resident needed hourly checks and needed to be on a locked unit;-The resident needed a structured setting where he/she could be monitored for mental status changes. Review of the resident's care plan, dated 11/03/25, showed the following:-The resident was at risk for the following signs or symptoms related to his/her diagnosis of schizophrenia: aggression, anxiety, delusions, false beliefs that cannot be reasoned with, and hallucinations;-The resident had a history of behavioral challenges that required protective oversight in a secure setting;-The resident had the potential to be physically aggressive related to poor impulse control. Review of the resident's progress note, dated 05/29/26 at 3:30 P.M. (documented as a late entry), showed the resident said he/she walked up to peer (Resident #4) to explain he/she had the situation wrong. Peer (Resident #4) grabbed the resident's shirt, and the resident attempted to walk away. Peer (Resident #4) continued to grab the resident's shirt, so the resident pushed him/her away and the resident walked away;-The psychiatric physician conducted a telepsych visit with the resident with no new orders or concerns. Review of the resident's care plan, dated 05/29/26, showed the following:-Staff spent one-on-one time with the resident;-Staff educated the resident on going to staff when he/she had an issue with other residents;-Staff educated the resident on not borrowing or letting other residents borrow money from him/her. Review of the resident's telepsych visit, dated 05/29/26, showed the following:-Telepsych evaluated the resident after the resident was the aggressor in an altercation with another resident;-No new orders or concerns were identified at this time. Review of the resident's telehealth notes, dated 05/29/26, showed the following:-The resident was involved in an altercation with another resident;-The resident said the altercation started as verbal over money and turned physical;-The physician planned to continue the current plan of care and medication regimen. Review of the resident's progress note, dated 06/07/26, showed the following:-The resident was verbally abusive with peers (Residents #5, #6, and #7); -The staff intervened and de-escalated the situation;-The resident received an as needed (PRN) medication and felt better. During interviews on 06/11/26 at 8:03 A.M. and 8:13 A.M., the resident said the following:-He/She and Resident #4 were in the dining room when they began yelling at each other;-Resident #4 pulled at his/her shirt and he/she pushed Resident #4 away and Resident #4 fell on the floor; -He/She hit Resident #4 several times in the head when Resident #4 was on the floor. During an interview on 06/11/26 at 8:03 A.M. and 8:13 A.M., the resident said the following:-He/She, along with Residents #5 and #6, went into Resident #7's room and had a talk with Resident #7 (on 06/07/26);-He/She told Resident #7 it would not be wise to snitch on him/her.-Staff separated the residents and removed them from Resident #7's room [ROOM NUMBER]. Review of Resident #6's PASRR, dated 05/27/15, showed the following:-The resident's diagnoses included schizoaffective disorder, bipolar personality disorder, paranoid schizophrenia, borderline intellectual functioning (impairment that impacts learning and reasoning);-The resident did not make good decisions, was easily frustrated, impatient and demanding, and struck others unprovoked;-The resident had a history of agitation, delusions, threatening others, and threatened to scalp a family member:-The resident required an increased level of care and supervision for safety and stabilization of symptoms;-The resident needed a structured environment and a systematic plan to change inappropriate behavior. Review of the resident's care plan, dated 07/07/25, showed the following:-The resident was at risk for the following signs and symptoms related to anxiety: cursing, hollering, and nervousness;-The resident had impaired coping;-The resident was at risk for harm, either self-directed or directed at others;-The resident had potential to be physically aggressive related to poor impulse control. Review of the resident's medical record on 06/11/26 showed staff did not document about the verbal altercation that took place in Resident #7's room. During an interview on 06/11/26 at 10:20 A.M., the resident said the following:-He/She went to Resident #7's room with Residents #3 and #5 on 06/07/26 because Resident #7 said Residents #3, #5, and #6 brought drugs to the facility and used drugs at the facility;-He/She told Resident #7 if he/she didn't quit running his/her mouth, they (Residents #3, #5, and #6) were going to beat the fuck out of him/her. 4. Review of Resident #5's PASRR, dated 09/06/23, showed the following:-The resident's diagnoses included schizoaffective disorder (mental health condition that included features of both schizophrenia and mood disorder), bipolar disorder; manic, severe, with psychotic features, and unspecified psychosis (mental disorder involving loss of contact with reality);-The resident had behavioral difficulties and/or mental illness symptoms that required 24-hour monitoring;-The resident had limited insight and poor judgment;-The resident needed continued monitoring of behavioral symptoms and a structured environment. Review of the resident's care plan, dated 3/17/26, showed the following:-The resident had a history of behavioral challenges that required protective oversight in a secure setting;-The resident had an impaired social interaction mood disorder. The resident was educated on appropriate interactions and boundaries with peers and staff;-The resident had a behavior problem related to bipolar and schizoaffective disorder;-Intervene as necessary to protect the rights and safety of others;-Monitor behavior episodes and attempt to determine underlying cause;-The resident had potential to be physically aggressive related to poor impulse control;-When the resident became agitated intervene before agitation escalates. Review of the resident's progress notes, dated 06/07/26, showed the following:-The resident was verbally abusive with peers;-Staff intervened and de-escalated the situation;-The resident was on 15-minute checks for protective oversight. During an interview on 06/11/26 at 10:31 A.M., the resident said he/she told Resident #7 to keep his/her name out of stuff because he/she (Resident #5) hadn't brought drugs into the facility recently. Review of the resident's physician order sheet, dated June 2026, showed an order on 06/07/26 for 50 mg chlorpromazine (an antipsychotic medication) for agitation and anxiety. Review of the resident's MAR, dated 06/07/26, showed CMT C administered 50 mg chlorpromazine for agitation and anxiety. Review of the resident's psychosocial post-incident impact note, dated 06/08/26, showed the resident did not directly involve himself/herself in the incident or witness the incident (no dates were documented for the incident or what the incident was about). 5. Review of Resident #7's PASRR, dated 07/24/18, showed the following:-The resident's diagnoses included bipolar disorder, attention deficit hyperactivity disorder, schizophrenia, learning disorder and borderline intellectual functioning;-The resident would benefit from a structured environment to reduce stress of daily living and to provide emotional support. Review of the resident's care plan, dated 07/27/2024, showed the following:-The resident had a safety plan that included music for distraction and/or comfort;-The resident was at risk for signs and symptoms related to anxiety, cursing and nervousness;-Offer non-invasive coping mechanisms first to try to reduce his/her anxiety level;-Offer medication before he/she had a behavioral outburst;-The resident was at risk for signs and symptoms related to a diagnosis of bipolar disorder;-Decrease stimulation around the resident when he/she displayed signs of anxiety;-Use a firm and calm approach;-The resident was at risk for signs and symptoms related to a diagnosis of schizophrenia;-Avoid arguing with or getting defensive the resident;-The resident had a history of behavioral challenges that required protective oversight in a secure setting;-Implement plans to change inappropriate behavior;-Use non-pharmaceutical interventions as needed, such as one-on-one with staff. Review of the resident's progress notes showed no documentation of an incident between this resident and Residents #3, #5, and #6 on 06/07/26. During an interview on 06/10/26 at 4:45 P.M., the resident said he/she did not know what Residents #3, #5, and #6 said on 06/07/26. (The resident would not look at the surveyor and changed the subject very quickly when asked about the incident.) 6. During an interview on 06/10/26 at 11:49 A.M., Certified Medication Technician (CMT) E said the following:-He/She was the team lead on the locked unit on 06/07/26;-Resident #16 told him/her Residents #3, #5, and #6 were in Resident #7's room arguing;-He/She arrived in Resident #7's room and all the residents were yelling and arguing;-He/She told all the residents to let it go. He/She told Residents #3, #5, and #6 to leave Resident #7's room;-He/She reported the incident to Licensed Practical Nurse (LPN) I and the nurse came to the locked unit;-All four residents cursed at each other after the incident throughout the day on 06/07/26. During interviews on 06/11/26 at 9:52 A.M. and on 06/12/26 at 10:45 A.M., LPN I said the following:-The staff on the locked unit told him/her Residents #3, #5, and #6 were going to beat up Resident #7; -He/She called the psychiatric nurse practitioner so all three residents could speak with him/her; -The psychiatric practitioner ordered a PRN antipsychotic for each of the three residents (Residents #3, #5, and #6).-He/She sent a group text to the Administrator, the DON, and the ADON and let them know there was an incident with Residents #3, #5, #6, and #7 and that he/she called the psychiatric nurse practitioner and got an order for PRN medications for Residents #3, #5, and #6. During an interview on 6/12/26 at 1:19 P.M., the Administrator said the following:-She was out of town on 05/29/26 (date of the incident involving Residents #3 and #4). The Regional Nurse was covering at the facility;-She did not know there was an incident with Residents #3, #5, #6, and #7 on 06/07/26. She was in the facility on the afternoon of 06/07/26 and staff did not report the incident to her;-She expected staff to notify her of incidents and altercations; -Residents #3, #5, and #6 threatened other residents in the past;-She felt it was Residents #3, #5, and #6 intent to intimidate other residents. She felt they were intelligent and used their intelligence to manipulate and intimidate residents. MO3028651

Based on interview and record review, the facility failed to develop and implement meaningful interventions, including non-pharmacological interventions and alternate strategies, to ensure residents on the secured locked unit were not witness to or personally affected by one resident's (Resident #5's) known, sexually inappropriate behaviors when Resident #5 made sexual comments to other residents, exposed his/her genitals to residents, and rubbed his/her genitals on other residents. Residents were upset by Resident #5's actions. The facility failed to investigate an incident involving three residents (Resident #3, #5 and #6) to identify and address the root cause for their behaviors after the residents intimidated and verbally threatened to harm one resident (Resident #7). A sample of eight residents was selected for review. The facility census was 111. Review of the facility's Behavioral Emergency Policy, revised 9/23/25, showed the following:-Non-physical interventions are the first choice as an intervention unless safety issues demand immediate physical intervention;-Proactive management for residents is the best plan. All staff should recognize when the resident has become or can become a danger to themselves or someone else. De-escalation techniques should be utilized as first resort;-Should the resident exhibit extreme behaviors such as resident-to-resident altercations, the following will occur; -The licensed nursing staff and/or nursing administration will assess the resident who is displaying signs of crisis, ensuring the safety of the resident and others is the priority. Monitoring of the resident will be initiated, if appropriate; -The facility's administrative team will assess to see if the resident's needs can continue to be met safely or whether the resident continues to be appropriate for placement at the facility; -The facility will notify the physician and/or psychiatrist of the behavioral emergency; -If the resident is unable to be redirected or is personally requesting an as needed (PRN) medication for mood stabilization, the resident will be given PRN medication per the physician's orders. If the resident receives a by mouth (PO) or intramuscular (IM) PRN mood stabilizing medication, the licensed nurse will document the administration and effectiveness;-The licensed nurse will document the behavioral emergency in the medical record;-The licensed nurse is responsible for notifying the administration, physician, and/or psychiatrist and the responsible party;-The Interdisciplinary Team (IDT) will ensure the care plan is updated if appropriate;-The administrative team will review the incident to determine root cause and review the situation for contributing factors. Reviewing staff responses and documentation to ensure the situation is reflected clearly;-A post incident review with staff members involved shall take place following the use of physical holds or medication administration for a behavioral emergency in order to determine what led to the incident and what could be done differently; root cause determination. The team shall review modifications to the treatment plan made during the crisis and develop a plan;-At regular intervals, the facility will review incidents to obtain root cause analysis which will facilitate improvements of care management and further prevention of incidents. 1. Review of Resident #5's Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care), dated 09/06/23, showed the following:-The resident's diagnoses included schizoaffective disorder (mental health condition that included features of both schizophrenia and mood disorder), bipolar disorder; manic, severe, with psychotic features, and unspecified psychosis (mental disorder involving loss of contact with reality);-The resident had behavioral difficulties and/or mental illness symptoms that required 24-hour monitoring;-The resident had limited insight and poor judgment;-The resident needed continued monitoring of behavioral symptoms and a structured environment. Review of the resident's Care Plan, dated 03/17/26, showed the following:-The resident had a history of behavioral challenges that required protective oversight in a secure setting;-The resident had an impaired social interaction mood disorder. Staff educated the resident on appropriate interactions and boundaries with peers and staff;-The resident had a behavior problem related to bipolar and schizoaffective disorder;-Intervene as necessary to protect the rights and safety of others;-Monitor behavior episodes and attempt to determine underlying cause;-The resident had potential to be physically aggressive related to poor impulse control;-When the resident became agitated, intervene before agitation escalates. Review of the resident's psychiatric notes, dated 05/20/26, showed the resident's sexual behaviors were not actively monitored on his/her problem list. Review of the resident's Progress Note, dated 06/05/26 at 2:49 A.M., showed the day shift reported the resident exposed his/her genitals, cussed, and made inappropriate sexual comments. Staff spoke with the resident about his/her behavior, and the resident said, I'm trying to get laid. Review of the resident's Care Plan showed staff did not update the plan with any interventions to address the resident's sexual behaviors documented in his/her progress note dated 06/05/26. Review of the resident's Physician Order Sheet, dated June 2026, showed an order on 06/07/26 for 50 mg chlorpromazine (antipsychotic medication) for agitation and anxiety. Review of the resident's Medication Administration Record (MAR), dated 06/07/26, showed Certified Medication Technician (CMT) C administered 50 mg chlorpromazine for agitation and anxiety. Review of the resident's Progress Note, dated 06/07/26 at 3:05 P.M., showed the following:-The resident was verbally abusive with peers;-Staff intervened and de-escalated the situation;-The resident calmly hung out in the dining room with peers;-Staff placed the resident on 15-minute checks for protective oversight. During interviews on 06/11/26 at 10:31 A.M. and 06/12/26 at 11:48 A.M., Resident #5 said he/she told Resident #7 to keep his/her name out of stuff because the resident hadn't brought drugs into the facility recently (on 06/07/26). During an interview on 06/12/26 at 11:48 A.M., the resident refused to talk about his/her sexual behaviors. The resident became agitated and asked the state surveyor to leave his/her room. During an interview on 06/12/26 at 8:52 A.M., the Activity Director said he/she had reported the resident's sexual behaviors to the management team and nursing staff, and nothing had been done about it. The resident exposed his/her genitals to residents and staff often. During interviews on 06/12/26 at 9:27 A.M. and 11:50 A.M., Resident #26 said the following:-Resident #5 exposed his/her genitals to residents and made sexual comments pretty regularly; -Resident #5 grabbed residents and humped them while his/her genitals were exposed;-He/She did not like it when the resident did that stuff, he/she tried to stay away from Resident #5. During an interview on 06/12/26 at 11:38 A.M., Resident #8 said Resident #5 exposed his/her genitals, swung his/her genitals around and said, I want to fuck you, as he/she got very close. Resident #8 told Resident #5 to stop because it was gross, and it made him/her uncomfortable. During an interview on 06/12/26 at 11:40 A.M., Resident # 9 said Resident #5 exposed his/her genitals to other residents and to him/her. Resident #5 got too close to him/her when he/she did that. He/She did not want to say anymore because he/she was afraid Resident #5 would hurt him/her. During an interview on 06/12/26 at 11:54 A.M., Certified Nurse Assistant (CNA) F said the following:-Resident #5 exposed his/her genitals all the time;-Resident #5 got aggressive with other residents at times when he/she exposed his/her genitals;-The resident grabbed other residents and humped on them while his/her genitals were exposed;-The Administrator and Director of Nursing (DON) knew the resident exposed his/her genitals to other residents. It had been reported many times;-The resident exposed his/her genitals in the dining room a lot; -The other residents didn't like it when Resident #5 exposed his/her genitals or humped on them. Staff were to separate Resident #5 from other residents when he/she acted in this way. During an interview on 0612/26 at 1:19 P.M., the Administrator said the following:-She was aware of Resident #5's sexual behaviors but did not know what to do about them;-She was aware the resident had inappropriate sexual behaviors and exposed his/her genitalia to other residents; -She expected staff to update Resident #5's care plan to reflect his/her sexual behaviors with interventions to address them. 2. Review of Resident #6's PASRR, dated 05/27/15, showed the following:-The resident had diagnoses that included schizoaffective disorder, bipolar personality disorder, paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), borderline intellectual functioning (impairment that impacts learning and reasoning);-The resident did not make good decisions, easily frustrated, impatient and demanding, and struck others unprovoked;-The resident had a history of agitation, delusions, threatening others, and threatened to scalp a family member:-The resident required an increased level of care and supervision for safety and stabilization of symptoms;-The resident needed a structured environment, and a systematic plan to change inappropriate behavior. Review of the resident's care plan, dated 07/07/25, showed the following:-The resident was at risk for the following signs and symptoms related to anxiety: cursing, hollering, and nervousness;-Offer medication before the resident had a behavioral outburst;-Offer non-invasive coping mechanisms first to try to reduce the resident's anxiety level. Assist with finding the cause of the anxiety;-The resident had impaired coping;-The resident had a risk for harm, either self-directed or directed at others;-Monitor for signs and symptoms of agitation;-Offer the resident alternatives to unacceptable situations;-The resident had potential to be physically aggressive related to poor impulse control;-Discuss the resident's behavior. Explain/Reinforce why the behavior was inappropriate and/or unacceptable. Review of the resident's progress note, dated 06/07/26 at 3:13 P.M, showed the following:-Staff administered a PRN antipsychotic medication for anxiety;-Staff did not document the resident was in Resident #7's room with Residents #3 and #5 and threatened Resident #7;-Staff did not document any interventions used per the resident's care plan regarding the incident. During an interview on 06/11/26 at 10:20 A.M., the resident said the following:-He/She went to Resident #7's room with Residents #3 and #5 on 06/07/26 because Resident #7 said Residents #3, #5, and #6 brought drugs to the facility and used drugs at the facility;-He/She told Resident #7 if the resident didn't quit running his/her mouth they were going to beat the fuck out of him/her;-He/She got a PRN medication to help him/her calm down after the incident. 3. Review of Resident #3's PASRR, dated 11/26/18, showed the following:-The resident had diagnoses that included schizophrenia, psychotic disorder (severe mental disorder that caused abnormal thinking and perceptions), and delusional disorder (serious mental illness where a person experienced one or more persistent fixed false beliefs);-The resident had occasional physical aggression toward staff and peers;-The resident did not make good decisions, destroyed property, and was verbally abusive and threatening;-The resident needed hourly checks and needed to be on a locked unit;-The resident needed a structured setting where he/she could be monitored for mental status changes. Review of the resident's Care Plan, dated 11/3/2025, showed the following:-The resident had a risk for the following signs or symptoms related to his/her diagnosis of schizophrenia: aggression, anxiety, delusions, false beliefs that cannot be reasoned with, and hallucinations;-The resident had a history of behavioral challenges that required protective oversight in a secure setting;-Staff should avoid arguing or getting defensive with the resident;-Implement plans to change inappropriate behavior, behavior management;-Non-pharmaceutical interventions; one-on-one;-Pharmaceutical interventions as needed. Review of the resident's care plan, updated 05/29/26, showed the following:-The resident had the potential to be physically aggressive related to poor impulse control;-The resident spent one-on-one time with staff;-Staff educated the resident on talking with staff when he/she had an issue with another peer;-Staff educated resident on not borrowing or letting residents borrow money from him/her;-Administer medications as ordered;-Psychiatric consult as indicated. Review of the resident's telehealth visit with the Psychiatric Nurse Practitioner, dated 05/29/26, showed the following:-The reason for the visit was an evaluation following a resident to resident altercation that the resident was the aggressor;-The resident felt safe, denied any safety concerns, or the need to speak with staff;-No new order or concerns were identified. Review of the resident's progress note, dated 06/07/26, showed the following:-The resident was verbally abusive with peers; -The staff intervened and de-escalated the situation;-The resident received an as needed (PRN) medication and felt better. During an interview on 06/11/26 at 8:03 A.M. and 8:13 A.M., the resident said the following:-He/She, along with Residents #5 and #6, went into Resident #7's room and had a talk with Resident #7. He/She told Resident #7 it would not be wise to snitch on him/her. Staff came in Resident #7's room and sent him/her, and Residents #5 and #6 out of the room. 4. Review of Resident #7's PASRR, dated 07/24/18, showed the following:-The resident had diagnoses that included bipolar disorder, attention deficit hyperactivity disorder, schizophrenia, learning disorder and borderline intellectual functioning;-The resident required monitoring of medications;-The resident would benefit from a structured environment to reduce stress of daily living and to provide emotional support; Review of the resident's progress notes showed no evidence staff documented an incident between Resident #7 and Residents #3, #5, and #6 on 06/07/26. During interviews on 06/10/26 at 4:45 P.M. and 06/12/26 at 12:05 P.M., Resident #7 said the following:-Residents #3, #5, and #6 came into his/her room on 06/07/26 but he/she did not want to talk about it;-He/She did not know what Residents #3, #5, and #6 said on 06/07/26; (During the interview, the resident would not look at the surveyor and changed the subject very quickly.) 5. During an interview on 06/10/26 at 11:49 A.M., CMT C said the following:-He/She was team lead on 06/07/26 on Resident #7's unit;-A resident (unknown) told him/her Residents #3, #5 and #6 were in Resident #7's room;-He/She went to Resident #7's room and all the residents were arguing and yelling at each other. He/She told Residents #3, #5, and #6 to leave and let it go;-The residents cursed at each other throughout the day but were fine later. During an interview on 06/11/26 at 9:52 A.M. and on 06/12/26 at 10:45 A.M., Licensed Practical Nurse (LPN) I said the following:-CMT C said Residents #3, #5, and #6 were going to beat up Resident #7;-Staff separated the four residents before he/she arrived on the unit; -Resident #3, #5, and #6 asked for a PRN medication. LPN I called the psychiatric nurse practitioner and all three residents spoke with him/her;-The psychiatric practitioner ordered a PRN antipsychotic for each of the three residents;-He/She sent a group text to the Administrator, the DON, and the Assistant Director of Nursing (ADON) and let them know there was an incident with Residents #3, #5, #6, and #7. He/She called the psychiatric nurse practitioner and got an order for PRN medications. During an interview on 6/12/26 at 1:19 P.M. the Administrator said the following:-She did not know there was an incident with Residents #3, #5, #6, and #7 on 06/07/26. She was in the facility on the afternoon of 06/07/26, and staff did not report the incident to her. Staff did not investigate the incident to identify a root cause;-Residents threatened each other all the time. Staff talked to the residents to find out the problem, got it resolved and then the residents were usually okay;-Residents #3, #5, and #6 had threatened other residents in the past;-She felt it was Residents #3, #5, and #6 intended to intimidate other residents. She felt they were intelligent and used their intelligence to manipulate and intimidate residents;-She could not keep reporting bad behaviors of certain residents because then she could not refer them to other facilities where they wanted to move;-She expected staff to implement interventions regarding behaviors that were on residents' care plans. During an interview on 06/26/26 at 4:41 P.M., the Psychiatric Nurse Practitioner said the following:-She began seeing Resident #5 in March 2026. At that time the resident had sexual behaviors where he/she exposed his/her genitals to other residents;-She was not aware Resident #5 had continued to have sexual behaviors. She thought the resident stopped those behaviors since there was no documentation in his/her medical record of the behaviors and the facility had not mentioned the behaviors to her since March. She saw the resident about one time a week;-She saw Resident's #3 and #6 at the facility regularly;-She felt Residents #3, #5, and #6 intimidated other residents.

Based on observation, interview, and record review, the facility failed to date, seal or cover food items, ensure the ice/water dispensing machines were free of a buildup of debris, to cover all facial hear with beard restraints, and to ensure the floor next to the kitchen ice machine was free of a buildup of debris. The facility census was 116. 1. Review of the undated facility policy, Food Storage, showed the following:-Label and date all storage containers as follows;-The date received should already be on it;-Date opened;-Date the item expires. Observation on 04/26/26 at 9:58 A.M. showed the following:-A refrigerator contained six pitchers of lemonade (one dated 4-25) and eight undated pitchers of tea;-A refrigerator contained ten uncovered and undated bowls of pudding and brownies. During an interview on 04/26/26 at 9:58 A.M., Dietary Staff Y said he/she was going to throw the bowls of pudding and brownies away but had not. He/She placed older pitchers of tea and lemonade in the front of the refrigerator, and he/she placed new/fresh pitchers in the back. He/She was supposed to date the pitchers. Observation on 4/27/26 at 9:30 A.M. of the kitchen dry storage room showed a large white plastic tub on wheels contained a 25-pound bag of all-purpose flour and a 25-pound bag of granulated sugar. The bags were open and there was no lid on the plastic tub. During an interview on 4/28/26 at 1:12 P.M., the Dietary Manager said staff should label food and drink items when they place them in the refrigerator. Staff should label, date and properly cover food items. Staff should cover the pudding cups on a tray and should date each bowl. Staff should date each beverage pitcher. The lid for the white tub that held the flour and sugar was missing. Staff should close or seal the bags of flour and sugar. 2. Review of the facility policy, Ice Machine, dated 2026 showed the following:-Operation of Equipment: See manufacturer's instructions for operation of ice machine;-Sanitation of Equipment: Frequency: Daily, Wash exterior of machine. Use sanitizing solution and clean cloth. Allow to dry;-Frequency: Monthly, Remove ice. Wash inside of machine. Use sanitizing solution and clean cloth. Allow to air dry. Observation on 4/29/26 at 8:29 A.M. showed the dispensing spouts on the ice/water dispensing machine in the Station One dining room had a buildup of white crusty debris, dark-colored debris, and rusty-colored debris. Observation on 4/29/26 at 11:16 A.M. showed the dispensing spouts on the ice/water dispensing machine in the Station Two dining room had a buildup of white crusty debris, dark-colored debris, and rusty-colored debris. During an interview on 4/29/26 at 8:29 A.M., the Maintenance Supervisor said the vendor came to the facility quarterly to maintain the ice machines. Maintenance was instructed not to touch the units as it would void the warranty. During an interview on 4/29/26 at 1:45 P.M., the Dietary Manager said the vendor maintained the ice/water dispensing machines in both dining rooms. The vendor kept the units working and performed deep cleaning/sanitizing, but she was unsure how often this was done. Dietary staff wiped off the exterior and should clean the dispensing spout when they discovered any debris. 3. Review of the undated facility policy, Personal Hygiene, showed the following:-These are the guidelines for personal hygiene to promote a safe and sanitary department;-Head covering worn;-Hair must be covered with a hairnet;-Beards or excessive body hair that may be exposed must be covered. Observation on 4/27/26 at 12:19 P.M. showed Dietary Staff O had facial hair, a beard and sideburns. Dietary Staff O wore a beard restraint on his/her chin, however; the beard restraint did not cover all exposed facial hair. Dietary Staff O stood over prepared plates of food on the tray line and placed desserts onto each tray. Observation on 4/27/26 at 12:31 P.M. showed Dietary Staff M had a moustache, a beard and sideburns and stood over steam table pans of food while plating food items on residents' meal trays. Dietary Staff M wore a beard restraint on his/her chin, however; the beard restraint did not cover all exposed facial hair. Observation on 4/28/26 at 12:16 P.M., showed Dietary Staff M had a moustache, a beard and sideburns and stood over steam table pans of food while plating two veggie burgers, vegetables and rice on a resident tray. Dietary Staff M wore a beard restraint on his/her chin, however; the beard restraint did not cover all exposed facial hair. During an interview on 4/28/26 at 1:12 P.M., the Dietary Manager said beard restraints should cover all facial hair. Staff needed to cover anything more than a light stubble. 4. Observation on 04/26/2026 at 9:58 A.M. showed an area of the tiled floor, located by the ice machine, which was soiled with dirt and dried food crumbs. During an interview on 4/28/26 at 1:12 P.M., the Dietary Manager said the dietary aides cleaned the floors. Staff should clean the floors daily on each shift. 5. During an interview on 5/5/26 at 2:11 P.M., the facility Consultant Dietitian said the following:-Food items should be labeled, dated, sealed or closed and appropriately covered. Beverage pitchers should be dated;-Beard restraints should cover sideburns and beards. She was unsure how moustaches would be handled;-The ice/water machines in the two dining rooms should be clean and free of debris. She had previously been told by dietary staff that the vendor had instructed staff to not touch these units and to contact vendor with issues;-Walls and floors should be clean and free of debris.

Based on observation, interview, and record review, the facility failed to develop complete policies and procedures to monitor the facility's water system and implement the facility policy to monitor for Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' disease) that included specific control parameters based on the Center for Disease Control and Prevention (CDC) and the American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE)) standards. The facility failed to follow current infection control standards for multiple residents, in a review of 30 sampled residents, and one additionally sampled resident. The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for one resident (Resident #44) when staff failed to perform hand hygiene to protect against the spread of infection. The facility failed to ensure staff washed their hands during medication administration for three residents (Residents #7, #10 and #53). Staff failed to clean insulin pen hubs before attaching a needle for administration of the medication for four residents (Residents #46, #56, #102 and #16). The facility failed to follow appropriate infection control standards when handling soiled linens for one resident (Resident #48) when staff placed soiled linens directly on the floor. The facility also failed to follow enhanced barrier precautions for one resident (Resident #71) when staff did not wear personal protective equipment (PPE) when changing linens on the resident's bed and failed to follow appropriate hand hygiene and gloving practices for two residents (Resident #12 and #113). The facility census was 116. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following:-Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water;-CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical and epidemiological considerations for healthcare facilities are described in this toolkit;-Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system;-Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;-Specify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. Review of the undated Centers for Disease Control and Prevention Legionella Environmental Assessment Form, showed Legionella generally grew well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Review of the Centers for Disease Control Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings Toolkit, dated 06/24/21, showed the following: -Clinicians should test patients with healthcare-associated pneumonia (pneumonia with onset 48 hours after admission) for Legionnaires' disease. This is especially important among patients at increased risk for developing Legionnaires' disease among patients with severe pneumonia (particularly those requiring intensive care), or if any of the following are identified in your facility; -Other patients with healthcare-associated Legionnaires' disease diagnosed in the past 12 months;-Positive environmental tests for Legionella in the past two months; -Current changes in water quality that may lead to Legionella growth (e.g., low residual disinfectant levels, temperatures permissive to Legionella growth, nearby construction, areas of stagnation); -Other patients, besides those with healthcare-associated pneumonia, should also be tested for Legionnaires' disease. The preferred diagnostic tests for Legionnaires' disease are culture of lower respiratory secretions on selective media and the Legionella urinary antigen test.-Symptoms of Legionella include headache, confusion, cough, shortness of breath, nausea, vomiting, diarrhea, fever, chills, tiredness, muscle or body aches;-Symptoms usually begin two to ten days after being exposed to Legionella. Review of the facility's Legionella Surveillance Policy, dated 06/24/24, showed the following:-It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections;-Legionella grows best in water temperatures of 77 degrees F and 108 degrees F, particularly in water that is not moving or that does not have enough disinfectant (i.e. pH 6.5-8.5) to kill germs;-Legionella can make people sick when the germs spread in droplets small enough for people to breathe in. Medical devices, cooling towers, showers, hot tubs, and fountains create aerosols;-Although uncommon, Legionella may be contracted by aspiration of contaminated drinking water;-Residents with health-care associated pneumonia or who have failed antibiotic therapy for community-acquired pneumonia shall be tested for Legionella using both cultures of lower respiratory secretions and the Legionella urinary antigen test;-Investigation for a facility source of Legionella, which may include culturing of both culture of lower respiratory secretions and the Legionella urinary antigen test;-Physical controls: a. cooling towers and potable water systems shall be routinely maintained; b. At-risk medical equipment shall be cleaned and maintained in accordance with manufacturer recommendations; c. Non-potable water systems shall be routinely cleaned and disinfected; d. Nebulization devices shall be filled only with sterile fluid;-Temperature controls: a. Cold water shall be stored and distributed below 68 degrees F; b. Hot water shall be stored above 140 degrees F and circulated at a minimum return temperature of 124 degrees F.-A description of how water is received and processed, stored, heated, cooled, recirculated, and delivered to end-point uses;-Include a piping and instrumentation diagram or process diagram for each of the potable (hot and cold) water systems in the building. The facility's policy did not address who was responsible for monitoring the facility's water management program, members of the water management team, specific items monitored with measurable parameters (i.e. temperature, chlorine levels etc.) or inspecting for scaling and biofilm. The facility also did not establish acceptable parameters or actions to take if values were outside of the parameters. Review of a map the facility provided related to the water lines showed the water lines in the facility were highlighted in blue. The map did not show the locations of the hot water heaters or how the water flowed through the building. The facility did not have any other documentation to show which hot water heaters supplied different areas of the facility or where the water lines started or stopped on the halls. Review of the facility's Water Temperature Log, dated February 2026, showed the facility monitored hot water temperatures. The log did not include the temperature of the cold water in the facility. Review of the facility's Water Temperature Log, dated March 2026, showed the facility monitored hot water temperatures. The log did not include the temperature of the cold water in the facility. Review of the facility's Water Temperature Log, dated April 2026, showed the facility monitored hot water temperatures. The log did not include the temperature of the cold water in the facility. Observation on 04/30/26 at 1:40 P.M. to 2:02 P.M., showed the following: -At 1:40 P.M., the temperature of the cold water in the tub in the 100 hall shower room, was 82.2 degrees F, and the temperature of the hot water was 106.5 degrees F (legionella generally grows well between 77 and 113 degrees F); -At 1:47 P.M., the temperature of the hot water at the sink in occupied resident room [ROOM NUMBER] (located at the end of the hall) sink was 74.8 degrees F after two minutes. The temperature of the hot water after five minutes was 112 degrees; -At 1:56 P.M., the temperature of the hot water at the sink in occupied resident room [ROOM NUMBER] was 105.2 degrees F after five minutes;-At 2:00 P.M., the temperature of the hot water at the sink in occupied resident room [ROOM NUMBER] was 106.1 degrees F. During an interview on 04/30/26 at 9:00 A.M., the interim Director of Nursing (DON) said she did not know about a water management team. During an interview on 04/29/26 at 3:45 P.M., the Maintenance Director said the following:-The maintenance staff checked hot water temperatures; -He was not sure what the hot water temperature range should be;-The maintenance staff did not check any cold water temperatures;-The facility had some water lines that went into the ceiling. He did not know if that affected the cold water temperatures with the changes to the weather because he had never checked the cold-water temperatures;-The facility tested for legionella when a vendor told them to; -The vendor sends a box, and the facility follows the directions;-There was no water management team;-He did not know what the CDC legionella tool kit was;-He did not follow the ASHRAE guidelines because he was not a professional;-The facility did not have a water flow map;-If a faucet was not working, staff changed out the faucet. Sometimes the faucet do not work because of buildup of sediment and/or scaling. During an interview on 04/29/26, at 12:21 P.M., and 4:16 P.M., the Administrator said the following:-She was the only certified Infection Preventionist for the facility at that time;-The water management committee was required to meet once a month;-The facility sent samples in to be tested for Legionella; -The facility monitored hot water temperatures;-She did not know what ASHRAE was;-She was not aware of any cases of Legionella in the facility; -If a resident had pneumonia that persisted and was not responding to antibiotics, they would ask to test for Legionella;-The last case of facility acquired pneumonia was in October 2025. At that time, staff did not test the resident for Legionella. 2. Review of the facility policy, Hand Hygiene, revised 6/26/24, showed the following:-All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors;-Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice;-Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations;-Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom;-The use of gloves does not replace hand hygiene;-If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 3. Review of resident #44's physician orders, dated 04/30/26, showed to monitor blood sugar (level of sugar in the blood stream) four times a day. Observation on 04/28/26 at 04:26 P.M., showed the following:-Certified Medication Technician (CMT) I did not perform hand hygiene and put on gloves;-CMT I prepared to obtain a blood sugar sample from the resident;-CMT I obtained the blood sample from the resident's finger, performed the blood sugar finger stick (BSFS) procedure by placing a blood-filled test strip in the glucometer, obtaining the result and then removing the blood filled test strip;-CMT I placed the blood glucose meter in the plastic box labeled with Resident #44's name;-CMT I removed his/her gloves and did not perform hand hygiene. During an interview on 04/28/26 at 4:32 P.M., CMT I said the following:-The procedure to perform a blood glucose check was to sanitize hands, put on gloves, and use a lancet to get the blood sample and get a reading;-He/She should perform hand hygiene before putting and taking off gloves;-He/She did not sanitize his/her hands and should have sanitized before he/she put on and took off his/her gloves. 4. Review of the facility's policy, Medication Administration, revised 06/26/24, showed the following: -Medications are administered as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. It is the policy of this facility to ensure the safe and effective administration of all medications by utilizing best practice guidelines;-Wash hands prior to administering medication per facility protocol and product;-Wash hands using facility protocol;-Perform hand hygiene before preparing medication and before and after direct contact with a resident. 5. Observation on 04/27/26 at 5:07 P.M. showed the following:-CMT AA stood in the hallway in front of the medication cart;-Without performing hand hygiene, CMT AA touched the computer keyboard, opened the medication cart, pulled bubble packs for Resident #15 from the cart, popped the medications from the bubble pack into a medication cup, and poured water into another cup;-Resident #15 stood at the medication cart. CMT AA handed the resident the medication cup, a wooden spoon and a cup of water and observed the resident take the medications; -CMT AA took the medication cup, wooden spoon and water cup from the resident and threw them in the trash;-CMT AA did not wash or sanitize his/her hands. Observation on 04/27/26 at 5:13 P.M. showed the following:-CMT AA stood in the hallway in front of the medication cart and had just completed administering medications to Resident #15;-Without washing or sanitizing hands, he/she touched the computer keyboard, opened the medication cart, pulled bubble packs for Resident #7 from the cart, popped the medications from the bubble pack into a medication cup, and poured water into another cup; -While popping the medication from the bubble pack, one pill fell to the floor. CMT AA picked up the pill and set it on the side of his/her computer keyboard;-CMT AA walked to Resident #7's room, handed the medication cup, a wooden spoon and a glass of water to the resident and observed the resident take the medications; -He/She took the medication cup, wooden spoon and water cup from the resident and threw them in the trash. CMT AA exited the room. He/She washed his/her hands with soap and water then exited the resident's room; -CMT AA walked back to the medication cart, picked up the pill from his/her computer, walked to the nurse's station, used the keypad to get into the nurses station, and placed the pill in a sharps container on the treatment cart which sat inside of the nurses' station;-CMT AA did not wash or sanitize his/her hands. He/She placed his/her hand on the door handle of the nurse's station door to let him/herself out;-CMT AA walked back down the hall to his/her medication cart. Observation on 04/27/26 at 5:22 P.M., showed the following:-CMT AA returned to the medication cart from disposing the dropped medication in the sharp's container in the nurses station; -Without washing or sanitizing hands, he/she touched the computer keyboard, opened the medication cart, pulled bubble packs for Resident #100 from the cart, popped the medications from the bubble pack into a medication cup and poured water into a cup;-He/She walked to Resident #100's room, handed the medication cup and a glass of water to the resident, observed the resident take the medications, then took the medication cup and water cup from the resident and threw them in the trash;-CMT AA did not wash or sanitize his/her hands. Observation on 04/27/26 at 5:26 P.M., showed the following:-CMT AA stood in the hallway in front of the medication cart and had just completed administering medications to Resident #100;-Without washing or sanitizing hands, he/she touched the computer keyboard, opened the medication cart, pulled bubble packs for Resident #10 from the cart popped the medications from the bubble pack into a medication cup and poured house supplement into a cup;-CMT AA handed the medication cup and a glass of water to Resident #10, then took the medication cup and water cup from the resident and threw them in the trash;-CMT AA did not wash or sanitize his/her hands. Observation on 04/27/26 at 5:33 P.M. showed the following:-CMT AA stood in the hallway in front of the medication cart and had just completed administering medications to Resident #10;-Without washing or sanitizing hands, he/she touched the computer keyboard, opened the medication cart, pulled bubble packs for Resident #53 from the cart, popped the medications from the bubble pack into a medication cup, and poured water into a cup;-CMT AA handed Resident #53 the medication cup, a wooden spoon and a cup of water, and observed the resident take the medications. CMT AA took the medication cup, wooden spoon and water cup from the resident and threw them in the trash;-CMT AA did not wash or sanitize his/her hands. During an interview on 04/28/26 at 4:06 P.M., CMT AA said he/she should wash his/her hands with soap and water before and after contact with residents. He/She could use hand sanitizer between each medication administration but did not have sanitizer with him/her while he/she passed medications on 4/27/26. He/She did not remember to wash his/her hands with soap and water or use hand sanitizer during medication administration on 4/27/26. During interviews on 04/30/26 at 2:50 P.M. and 05/05/26 at 11:48 A.M., the Administrator said the following:-She expected staff to wash their hands with soap and water before and after providing care;-When administering medications, staff should wash their hands with soap and water between residents, after passing the medications to the resident, and before popping medications out of medication cards into medication cups. 6. Review of the facility policy, Administration of Insulin, revised 05/14/24, showed the following:-Purpose: It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. It is also the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge;-Attach pen needle: Remove the cap from the insulin pen; Wipe the rubber seal with an alcohol pad; Screw the pen needle onto the insulin pen. Review of the Lantus Solostar (prefilled pen of long-acting injectable medication used to treat diabetes) manufacturer's guidelines, revised 11/2018, showed the following procedure to attach the needle:-Wipe the rubber seal with alcohol;-Remove the protective seal from a new needle;-Line up the needle with the pen and keep it straight as you attach it (screw or push on, depending on the needle type). Review of Humalog (rapid-acting injectable medication used to treat diabetes, also known as insulin lispro) manufacturer's administration guidelines, revised 07/2023, showed the following:-Wipe the rubber seal with an alcohol swab;-Select a new needle;-Pull off the paper tab from the outer needle shield;-Push the capped needle straight onto the pen and twist the needle on until it is tight. 7. Review of Resident #6's physicians order summary, dated April 2026, showed the following:-Lantus SoloStar subcutaneous solution pen injector 100 units/mL, inject 28 units subcutaneously (beneath the skin) at bedtime;-Humalog Kwik pen subcutaneous solution pen injector 100 units/mL, inject per sliding scale (an amount to be determined based off a finger stick procedure). Observation on 04/27/26 at 8:22 P.M., showed Licensed Practical Nurse (LPN) BB removed the resident's Lantus insulin pen from the medication cart and removed the cap from the insulin pen. LPN BB did not clean the hub of the insulin pen with an alcohol pad. He/She applied the needle to the hub and administered the resident his/her insulin. Observation on 04/27/26 at 8:28 P.M., showed LPN BB removed the resident's Humalog insulin pen from the medication cart and removed the cap from the insulin pen. LPN BB did not clean the hub of the insulin pen with an alcohol pad. He/She applied the needle to the hub and administered the resident his/her insulin. 8. Review of Resident #56's physicians order summary, dated April 2026, showed the following:-Lantus SoloStar subcutaneous solution pen injector 100 units/mL, inject 13 units subcutaneously at bedtime;-Humalog kwik pen subcutaneous solution pen injector 100 units/mL, inject per sliding scale. Observation on 4/27/26 at 8:32 P.M., showed LPN BB removed the resident's Lantus insulin pen from the medication cart and removed the cap from the insulin pen. LPN BB did not clean the hub of the insulin pen with an alcohol pad. He/She applied the needle to the hub and administered the resident his/her insulin. Observation on 04/27/26 at 8:33 P.M., showed LPN BB removed the resident's Humalog insulin pen from the medication cart and removed the cap from the insulin pen. LPN BB did not clean the hub of the insulin pen with an alcohol pad. He/She applied the needle to the hub and administered the resident his/her insulin. 9. Review of Resident #102's physicians order summary, dated April 2026, showed an order for Lantus SoloStar subcutaneous solution pen injector 100 units/mL, inject 18 units subcutaneously at bedtime. Observation on 04/27/26 at 8:46 P.M., showed LPN BB removed the resident's Lantus insulin pen from the medication cart and removed the cap from the insulin pen. LPN BB did not clean the hub of the insulin pen with an alcohol pad. He/She applied the needle to the hub and administered the resident his/her insulin. 10. Review of Resident #16's physicians order summary, dated April 2026, showed the following:-Lantus SoloStar subcutaneous solution pen injector 100 units/mL, inject 12 units subcutaneously at bedtime;-Insulin lispro subcutaneous solution pen injector 100 units/mL, inject per sliding scale. Observation on 04/27/26 at 8:52 P.M., showed the following:-LPN BB removed the resident's Lantus insulin pen from the medication cart and removed the cap from the insulin pen. Without cleaning the hub of the insulin pen with an alcohol pad, he/she applied the needle to the hub and administered the resident his/her insulin;-LPN BB removed the resident's insulin lispro pen from the medication cart and removed the cap from the insulin pen. Without cleaning the hub of the insulin pen with an alcohol pad, he/she applied the needle to the hub and administered the resident his/her insulin. During an interview on 04/28/26 at 5:57 P.M., LPN BB said he/she never cleaned the hub of the insulin pen before he/she attached a new needle. He/She did not know the hub needed to be cleaned with alcohol before attaching a new needle. During interviews on 04/30/26 at 2:50 P.M. and 05/05/26 at 11:48 A.M., the Administrator said staff should clean the hubs of insulin pens with an alcohol pad before attaching a new needle to prevent contamination of the medication. 11. Review of the facility policy, Handling Clean and Dirty Linen, revised on 06/26/24, showed the following:-It is the policy of this facility to handle, store, process and transport clean and soiled linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection;-Contaminated linen is linen that has been soiled with blood or other potentially infectious materials;-All used linen should be handled using standard precautions (i.e., gloves) and treated as potentially contaminated. Examples of linen that may require special handling include, but are not limited to, visibly soiled with blood or large amounts of body fluids;-Linen should not be allowed to touch the uniform or floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons;-Used or soiled linen shall be collected at the bedside (or point of use, such as dining room) and placed in a linen bag or designated, lined receptacle. 12. Observation on 04/29/26 at 1:25 P.M., showed the following: -Certified Nurse Assistant (CNA) C and Nurse Assistant (NA) G provided incontinence care for Resident #48;-The resident had been incontinent of bowel and bladder;-The resident's gown, top sheet, cloth incontinence bed pad, and fitted sheet were heavily soiled with urine and/or soiled with feces; -CNA C removed the resident's soiled clothing, soiled linen and sat them directly on the floor by the resident's sink;-CNA C picked the soiled linens off the floor, placed them in a trash bag and removed the soiled linen from the room;-Staff did not sanitize the floor. During an interview on 04/29/26 at 1:25 P.M. and 4/30/26 at 4:13 P.M., CNA C said the following:-He/She knew linens should never touch the floor;-He/She ran out of bags and had nowhere else to put the soiled linens, so he/she made a choice to put them on the floor to continue providing care to the resident that had a large incontinent episode;-Soiled linen should be put in a trash bag;-Soiled linens should not be put on the floor due to infection control and contamination purposes. During an interview on 04/30/26, at 2:50 P.M., the Administrator said the following:-Dirty linens should not be placed on the floor;-If staff put soiled linens on the floor, they should sanitize the floor after the dirty linens were removed. 13. Review of the facility policy, Enhanced Barrier Precautions, revised 5/18/24, showed the following:-It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms;-Enhanced Barrier Precautions (EBP) is a strategy in nursing homes to decrease transmission of CDC-targeted and epidemiologically important multidrug-resistant organisms (MDROs) when contact precautions do not apply. EBP uses personal protective equipment (PPE) and recommends gown and glove use for certain residents during specific high-contact resident care activities associated with MDRO transmission. EBP expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated. EBP uses gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing;-EBP (gown and gloves) must be used for high-contact resident care activities for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO;-High-contact resident care activities include, but are not limited to, dressing, bathing/ showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, indwelling device care or use, or wound care;-Indwelling medical devices include, but are not limited to, central lines, urinary catheters, feeding tubes, and tracheotomies; -Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray. 14. Review of Resident #71's care plan, updated 11/5/25, showed he/she had an indwelling urinary catheter. Observation on 04/30/26 at 7:49 A.M. showed the resident did not have a sign on or near his/her room indicating he/she was on EBP and there was no PPE readily available in the hallway or resident room. Observation on 04/30/26 at 8:29 A.M. showed the following:-NA T wore a gown and gloves and emptied urine from the resident's urinary catheter drainage bag. NA T did not wear face protection to protect against splash; -NA S changed the linens on the resident's bed. NA S wore gloves but did not wear a gown. During an interview on 04/30/26 at 9:36 A.M., NA S said the following:-He/She wore EBP when providing care for residents with catheters, wounds, feeding tubes, and certain infections;-Gown and gloves were required when providing care to residents on EBP. A mask may be required depending on the type of infection;-He/She normally only wore gloves when changing the linens for residents on EBP; '-The charge nurse and the aides told him/her who was on EBP. There was not always a sign on the resident's door, but that would be helpful. 15. Observation on 4/29/26 at 1:07 P.M. showed the following:-LPN F entered Resident #12's room to administer the resident's tube feeding and medications; -LPN F set the necessary supplies on the resident's bedside table, did not perform hand hygiene, and put on gloves;-LPN F opened a capsule and poured the contents into a cup, removed his/her gloves, and did not perform hand hygiene;-LPN F put on shoe covers and a gown and did not perform hand hygiene;-LPN F did not put on gloves. He/She prepared the ordered medications, individually, by adding approximately 10 mL of water to each and stirring with a stir stick; -LPN F did not perform hand hygiene and put on gloves; -LPN F administered the resident's tube feeding, rinsed the supplies, and removed his/her gloves, gown, and shoe covers. LPN F did not perform hand hygiene before leaving the resident's room. During an interview on 04/29/26 at 1:42 P.M., LPN F said he/she should have washed his/her hands before entering the resident's room, starting the medication and tube feeding administration, with glove changes, and after finishing. He/She forgot to do so. 16. Review of Resident #113's physician order sheet (POS), dated April 2026, showed the following:-Insulin lispro subcutaneous solution pen-injector 100 units/milliliter (ml), inject as per sliding scale; 150-200 give 2 units, 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351+ notify physician, give subcutaneously with meals;-Lantus insulin subcutaneous solution 100unit/mL, inject 5 units subcutaneously one time a day. Observation on 04/29/26 at 12:28 P.M. showed the following:-LPN F sat the blood sugar finger stick supplies on the dining room table;-LPN F did not perform hand hygiene and was not wearing gloves;-LPN F completed the resident's blood sugar finger stick;-LPN F sanitized his/her hands, but did not apply gloves;-LPN F administered the insulin into the resident's left arm;-LPN F did not perform hand hygiene. During an interview on 04/29/26 at 1:42 P.M., LPN F said the following:-He/She completed the resident's blood sugar finger stick and insulin administration without wearing gloves;-He/She completed hand hygiene in the medication room before coming out to administer the medication;-He/She did not perform hand hygiene at the table prior to completing the resident's blood sugar finger stick or after administering the resident's insulin;-He/She realized after starting the process that he/she did not have any gloves;-He/She should have stopped to get gloves and restarted, but instead he/she chose to finish the process without gloves.

Based on observation, interview, and record review, the facility failed to ensure staff placed call lights within the resident's reach for five residents (Residents #48, # 12, #71, #11, and #79), in a review of 30 sampled residents, as directed in the resident's plan of care and per facility policy. The facility census was 116. Review of the facility policy, Call Lights Accessibility and Timely Response, revised on 04/30/24, showed the following:-The purpose of this policy is to ensure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response;-Staff will ensure the call light is within reach of the resident and secured, as needed;-The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 1. Review of Resident #48's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/29/26, showed the following:-Cognitively intact;-Able to make needs known, made self understood, and understood others;-Independent for transfers. Review of the resident's progress notes, dated 04/18/26, showed the following:-At 8:59 A.M., staff heard the resident yelling. Staff found the resident on the floor face down and complained of left shoulder discomfort. The resident was sent to the local hospital for evaluation and treatment;-At 2:54 P.M., the resident returned to the facility with a left humeral head (upper arm) fracture. Review of the resident's care plan, updated on 04/20/26, showed the following:-The resident was at risk for falls related to psychoactive drug use. The resident fell on [DATE] related to poor balance and unsteady gait;-Be sure the resident's call light is within reach and encourage him/her to use it for assistance as needed. Review of the resident's progress notes, dated 04/25/26 at 3:01 A.M., showed the resident had been stand-by assistance from one staff for ADLs, toileting and when up walking. Staff educated the resident on the importance of using his/her call light when needing assistance. Observation on 04/26/26 at 3:39 P.M., showed the resident lay in bed awake. The call light lay on the recliner out of the resident's reach. During an interview on 04/26/26 at 3:39 P.M., the resident said he/she knew how to use his/her call light, but he/she could not reach it. He/She needed more help, because he/she fell last week. Observation on 04/29/26 at 1:00 P.M., showed the resident lay awake in bed. The resident was incontinent of bowel and bladder. The call light lay on the resident's recliner out of the resident's reach and was covered with a blanket. During an interview on 04/29/26 at 1:00 P.M., the resident said he/she could not go to the bathroom by himself/herself. He/She knew how to use the call light but was unsure where it was. During an interview on 04/29/26 at 1:25 P.M., Certified Nursing Assistant (CNA) C said the resident could use his/her call light if he/she could reach it. 2. Review of Resident #12's admission MDS, dated [DATE], showed the following:-No speech, absence of spoken words;-Usually able to make self understood and to understand others;-Cognitively intact;-Required maximum assistance for bed mobility and transfers. Review of the resident's care plan, revised 3/13/26, showed the following:-The resident was totally dependent on one staff for repositioning and turning in bed;-The resident required one staff to transfer between surfaces;-Encourage the resident to use bell to call for assistance;-The resident had a communication problem;-Ensure/provide a safe environments: call light in reach. Observation on 04/27/26 at 6:28 P.M. showed the following:-Staff found the resident sitting on the ground beside bed;-Licensed Practical Nurse (LPN) BB and Certified Nurse Assistant (CNA) CC arrived to assess the resident and assist the resident back to bed;-LPN BB asked the resident if he/she was comfortable in the bed, placed the wheelchair next to bed, and left the resident's room;-The resident's call light was coiled up around the resident's footboard, at the end of the bed, and was not in the resident's reach. 3. Review of Resident #71's care plan, updated 3/13/26, showed the following:-He/She had an activities of daily living (ADL) self-care performance deficit;-He/She was at risk for falls;-Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed;-The resident needs prompt response to all requests for assistance. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Independent for all mobility. Observation on 04/26/26 at 3:16 P.M. showed the residents sitting in bed. The resident's call light lay on the ground under the bed and was not in the resident's reach. Observation on 04/30/26 at 7:49 A.M. showed the resident was asleep in bed. The resident's call light lay on the ground under the resident's bed and was not in reach. 4. Review of Resident #11's care plan, revised on 03/18/26, showed the following:-He/She required a mechanical lift for all transfers due to impaired mobility, weakness, and/or inability to safely bear weight;-Keep call light and personal items within reach after transfer;-He/She is at risk for falls related to confusion, gait/balance problems, and use of cardiac and psychoactive medications;-Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Review of the resident's MDS, dated [DATE], showed the resident was dependent on staff for all transfers. Observation on 04/29/26, at 3:25 P.M., showed the lay asleep in bed. The resident's call light was clipped to the light fixture and out of the resident's reach. 5. Observation on 04/30/26, at 2:25 P.M. showed Resident #79 sat in his/her wheelchair next to the bed in his/her room. The resident faced the foot of his/her bed. The resident's call light was attached at the very head of the bed on the side of the mattress far behind the resident (approximately 3 feet behind the resident's wheelchair). During an interview on 04/30/26 at 2:25 P.M., the resident said he/she did know where his/her call light was. He/She asked if his/her call light was on the floor. After telling the resident where his/her call light was, the resident said there was no way he/she could reach his/her call light. He/She hated it when staff put his/her call light there because he/she cannot reach it to call for help. 6. During an interview on 04/30/26 at 4:13 P.M., CNA C said the call lights should always be in the residents' reach. During an interview on 04/30/26 at 4:15 P.M., Nurse Assistant (NA) S said call lights should always be in the resident's reach. During an interview on 04/30/26 at 02:50 P.M., the Administrator said staff should always leave call lights within reach for every resident.

Based on observation, interview, and record review, the facility failed to maintain a homelike environment, keeping the floors, walls, privacy curtains and windows in good repair and working order in the facility. The facility census was 116. Review of the facility's undated policy, Environment, showed the following:-The facility will be maintained in a safe, clean, comfortable and homelike setting;-Housekeeping and maintenance service in the dietary department will maintain a sanitary, orderly and comfortable dining area;-A homelike environment will be maintained with attractive tables, decor, and a pleasant dining area atmosphere. Review of the facility's policy, Safe and Homelike Environment, revised 06/05/24, showed the following:-In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment; -Environment refers to any environment in the facility that is frequented by residents, including but not limited to, the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas;-The facility will create and maintain, to the extent possible, a homelike environment that de-emphasizes the institutional character of the setting;-Housekeeping and maintenance services will be provided as necessary to maintain a sanitary and comfortable environment.-Report any unresolved environmental concerns to the Administrator. 1. Observation in occupied resident room [ROOM NUMBER] on 04/26/26 at 11:44 A.M., showed the following:-Large amounts of dust accumulated on the exhaust fan in the shared bathroom;-A strong urine odor in the shared bathroom;-No toilet paper holder in the bathroom; a roll of toilet paper sat on the handrail;-A large piece of the porcelain sink was missing and exposed the black underlaying of the bowl;-Multiple scraped areas on the door exposing the wood underneath. During an interview on 04/26/26 at 11:44 A.M., the resident, who resided in room [ROOM NUMBER], said it would be nice to have some place to put the toilet paper because the toilet paper fell on the floor frequently. 2. Observation on 04/29/26 at 1:25 P.M., showed the privacy curtain between the two beds in resident room [ROOM NUMBER] was broken and did not completely close around the beds. During an interview on 04/29/26 at 1:25 P.M., Certified Nursing Assistant (CNA) C said he/she was unable to pull the privacy curtain because it was broken. 3. Observation in occupied resident room [ROOM NUMBER] on 04/29/26 at 9:31 A.M. showed the following:-Multiple areas of dry wall on the wall around the television mount was patched and not painted;-Multiple areas of dry wall on the wall by bed A was patched and not painted. During an interview on 04/29/26 at 9:31 A.M., the resident who resided in the room said he/she moved into the room in June or July 2025 and the walls had been like this the entire time. 4. Observation in occupied resident room [ROOM NUMBER] on 04/27/26 at 6:14 P.M., showed the following:-A large area, approximately 2 feet by 3 feet, behind the door to the room had been patched and was not sanded or painted;-A large area on the wall, at the end of the bed, had been patched and was not sanded or painted;-A small area above the resident's bed had been patched and was not sanded or painted;-Areas on the wall were painted, however, the paint did not match;-A board covered the window. During an interview on 04/27/26 at 6:14 P.M., the resident who resided in room [ROOM NUMBER] said the board covered the window since August 2025, and the walls were patched about six months ago. It would be nice to have a nice-looking room. 5. Observation in occupied resident room [ROOM NUMBER] on 04/28/26 at 01:00 P.M., showed the following:-An area of dry wall, approximately the size of a basketball, located in the bathroom, was patched and painted and was dented in and not smooth like the rest of the wall;-An area of dry wall, approximately 30 inches by 24 inches, on the wall by the bathroom, was patched and not painted. During an interview on 04/28/26 at 01:00 P.M., the resident who resided in room [ROOM NUMBER] said the bathroom wall had been like that for two and half years, and the wall outside the bathroom had been like that for a year to year and half. 6. Observation on 04/27/26, at 6:30 P.M. of the Station Two shower room on the 600 hall showed the following:-Rusted base board heaters on the wall under the window;-Peeling paint on the window frame;-Peeling paint on the floor and at the base of the walls;-A black substance was on the lower part of the wall next to the floor and extended up the wall approximately 8 inches in some areas;-Missing paint on the wall dividing the shower and tub area;-The mirror had lost finish and was dull and had white dots and smears;-A large piece of plastic covered the back of the toilet that did not fit properly. 7. Observation on 04/27/26, at 6:37 P.M., in the Station Two dining room showed a board covered a large window. The curtains covering all the windows were in disrepair; two window curtains were torn into pieces. The curtains were not attached at the top in several areas allowing the curtains sag and looked like they were falling down. 8. Observation on 04/28/26, at 3:12 P.M. of the Station Two shower room on the 500 hall showed the following:-Peeling paint on the shower floor and a black substance on the floor around the base of the shower;-Peeling paint on the shower enclosure walls and a black, mold-like substance around the base of the shower;-Large clumps of hair on the shower floor, on the floor by the tub, and on the floor by the toilet;-The corner wall beside the toilet was discolored around the toilet paper holder, and there was brown build up in the corner between the toilet and the wall. 9. During an interview on 04/28/26, at 2:40 P.M., Certified Medication Technician (CMT) I said the following:-If something needed repaired, the facility has an app for maintenance;-Staff were to put any needed repairs in the app for maintenance staff. During an interview on 04/29/26 at 1:25 P.M., Nursing Assistant (NA) G said staff used an app to report areas that needed repaired to maintenance staff. During an interview on 04/26/26, at 10:00 A.M., Houskeeper FF said the following:-The facility had an app to report needed repairs;-Staff reported anything that was broken or needed fixed. During an interview on 04/29/26, at 3:45 P.M., the Maintenance Supervisor said the following:-The facility had an app employees used to report repairs that needed completed;-The maintenance staff tried to patch holes quickly but had not had time to sand and paint them all;-The shower room floors were an ongoing issue and were painted several times;-The boards on the windows in the dining room and room [ROOM NUMBER] were ordered. The facility was waiting on the vendor. It had been over six months,. He did not know when the windows would be fixed. He was not sure if the Administrator had contacted the vendor recently;-Housekeeping was responsible for cleaning and the curtains;-Department heads completed environmental rounds. During an interview on 04/30/26, at 2:35 P.M., the Administrator said the following:-She expected staff to put in repairs needed to maintenance app;-The program notified the maintenance staff when someone put in a work request, and then notified management if the repairs were not done in 24 hours;-Staff should complete repairs within a couple days;-The Maintenance Director followed up her if he ran into issues getting things completed;-The shower rooms were a work in progress;-Department heads and aides conduct environmental rounds and should put anything needing fixed into the app.

Based on interview and record review, the facility staff failed to report a resident-to-resident altercation for two residents (Resident #88 and #23), in a review of 30 sampled residents, to the Administrator when Resident #23 struck Resident #88, per the facility's abuse policy. The facility census was 116.Review of the facility policy, Abuse and Neglect, updated 06/12/24, showed the following:-It is the policy of this facility to ensure all allegations of abuse are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;-Abuse is the willful infliction of injury which can include certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, and physical abuse;-Verbal abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless their age, ability to comprehend, or disability. This includes using profanity or speaking in a demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence.-Physical abuse includes purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner.-When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the licensed nurse will notify the Administrator or designee, notify the attending physician, resident's family/legal representative, and medical director. 1. Review of Resident #88's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 04/18/26, showed the following:-Cognitively intact;-No hallucinations, delusions, or behaviors;-Diagnoses include schizophrenia (Serious mental illness that affects how a person thinks, feels, and behaves), schizoaffective bipolar type (mental health condition that includes features of both schizophrenia and a mood disorder), personality disorder, and anxiety. During an interview on 04/26/26 at 1:51 P.M., Resident #88 said the following:-A staff member was talking about his/her child, and he/she (Resident #88) said the child was probably gay; -He/She didn't understand why, but Resident #23 started punching him/her in the arm and chest;-He/She had to threaten Resident #23 to get him/her to stop punching him/her;-He/She was able to hold himself/herself back from striking Resident #23 back at that time, but he/she felt set up for failure;-He/She could not let people just beat on him/her and not react much longer;-He/She was worried Resident #23 would try it when he/she was having a bad day, and it would get him/her in trouble. 2. Review of Resident #23's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-No hallucinations, delusions, or behaviors;-Diagnoses include traumatic brain injury, anxiety disorder, depression, bipolar, schizophrenia, post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing terrifying, life-threatening events like abuse or combat), impulse disorder, dysthymic disorder (long term depression). During an interview on 04/26/26 at 11:09 A.M., Resident #23 said the following:-A staff member was talking about his/her child and Resident #88 said the child was gay;-It made him/her mad because Resident #88 was talking about a child, and he/she punched Resident #88 four to five times;-Then Resident #88 threatened he/she was going to kill him/her (Resident #23) or put him/her in the hospital;-He/She was still upset and Resident #88 better not mess with him/her again today. He/She was ready for him/her. 3. During an interview on 04/26/26 at 11:15 A.M., Resident #119 said the following:-He/She saw the whole incident between Resident #23 and Resident #88;-Resident #88 punched Resident #23 a bunch of times;-Resident #88 then called Resident #23 a bitch and kept saying try it one more time, and he/she would kill him/her or put him/her in the hospital;-Certified Medication Technician (CMT) B separated the residents. During an interview on 04/26/26, at 11:45 A.M., CMT B said the following:-That morning (4/26/26) around 9:30 A.M. during smoke break, Resident #88 said something about an employee's child that Resident #23 did not like;-Resident #23 started punching Resident #88 in the arm and yelled at him/her;-He/She stepped between the residents;-Resident #88 called Resident #23 names and yelled at him/her because he/she was upset about being punched;-It took a minute to get the residents calmed down, but staff separated them and then notified the interim Director of Nursing. During an interview on 04/26/26, at 4:15 P.M., the interim Director of Nursing said the following:-She felt the incident between Resident #23 and Resident #88 was reported to him/her this morning, but some details were left out or she missed the details;-She did not realize or did not process that it was a physical altercation;-She thought it was more of an argument;-He/She did not notify the Administrator because he/she did not realize it was a physical altercation. During an interview on 04/26/26, at 4:06 P.M., the Administrator said the following:-Staff did not notify her a resident-to-resident altercation that day (4/26/26),-No one reported to her that Resident #23 struck Resident #88 or that they had a verbal exchange;-She expected staff to report resident-to-resident altercations to her immediately after the residents were separated and safe.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for three residents (Residents #2, #70 and #10), in a review of 30 sampled residents. The facility census was 116. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.20.1, Chapter 1, revised October 2025, showed the following:-Comprehensive MDSs include admission, annual, significant change in status assessment and significant change in prior assessment;-The Resident Assessment Instrument (RAI) process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that:(1) the assessment accurately reflects the resident's status;(2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals;(3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. 1. Review of Resident #2's face sheet showed the resident had a guardian and diagnoses included muscle weakness, unsteadiness on feet, other abnormality of gait and mobility, lack of coordination, and repeated falls. Review of the resident's progress notes, dated 10/7/25 at 3:42 A.M., showed the resident was found on the floor of his/her room, lying next to the bed on his/her stomach. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff, dated 12/8/25, showed no falls since the prior assessment. Review of the resident's progress notes, dated 12/18/25 at 3:10 P.M., showed the resident fell to the floor and landed on his/her buttocks. Review of the resident's progress notes, dated 1/06/26 at 7:55 A.M., showed the resident fell out of his/her wheelchair onto the floor and hit his/her head. Review of the resident's skin issues assessment, dated 2/03/26, showed a new stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough, may also present as an intact or open/ruptured blister) pressure ulcer, in-house acquired, located on the intergluteal cleft (crease between the buttocks). The pressure ulcer measured 1.19 centimeters (cm) long by 1.78 cm wide by 1.52 cm deep. Review of the resident's physician orders, dated 2/10/26, showed an order to apply gauze to the gluteal cleft after cleansing with soap and water or wound cleanser, one time a day for wound care. Review of the resident's progress notes, dated 2/11/26 at 10:47 A.M., showed staff found the resident lying on the fall mat on the floor beside his/her bed. Review of the resident's progress notes, dated 3/06/26 at 8:45 A.M., showed staff witnessed the resident fall and hit the left side of his/her face on the floor. Review of the resident's quarterly MDS, dated [DATE], showed the following:-No falls since last assessment (completed on 12/8/25);-No unhealed pressure ulcers. Review of the resident's physician orders, dated 3/11/26, showed an order to discontinue applying gauze to the gluteal cleft after cleansing with soap and water or wound cleanser, one time a day for wound care. Review of the resident's progress notes dated 3/27/26 at 2:35 P.M. showed staff found the resident on his/her stomach on the fall mat with blankets under him/her. Review of the resident's skin issues assessment, dated 3/27/26, showed stable (previously deteriorating wound characteristics plateaued), stage II pressure ulcer, located on the intergluteal cleft, measuring 0.82 cm long by 1.5 cm wide by 0.1 cm deep. Review of the resident's progress notes, dated 3/29/26 at 2:32 P.M., showed staff found the resident on the fall mat by the bed with the covers under him/her. Review of the resident's progress notes, dated 4/01/26 at 2:41 P.M., showed staff found the resident on the fall mat on the floor, resting on his/her left side, with the covers underneath him/her. Review of the resident's progress notes, dated 4/01/26 at 7:30 P.M., showed staff found the resident face down on his/her floor by the bed. His/Her legs were on the fall mat, but his/her top half of body was on the bare floor. Review of the resident's progress notes, dated 4/06/26 at 7:30 P.M. showed staff found the resident on his/her bedroom floor, face down on the fall mat beside the bed with both arms under his/her chest. Review of the resident's significant change MDS, dated [DATE], showed no falls since the last assessment (completed on 3/10/26). 2. Review of Resident #70's face sheet showed the resident's diagnoses included blindness in one eye and low vision in the other eye. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Vision: adequate: sees fine detail, such as regular print in newspapers/books;-Cognitively intact;-Supervision or touching assistance for personal hygiene and wheeling 50 feet with two turns;-Partial/Moderate assistance for eating, oral hygiene, toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear and wheeling wheelchair 150 feet;-Substantial/maximal assistance or upper body dressing, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer;-Frequently incontinent of urine;-Occasionally incontinent of bowel;-Diagnosis of blindness, one eye, low vision other eye. Observations on 04/26/26 through 04/30/26 showed the following;-The resident independently ate multiple meals after staff delivered the resident's tray;-Self-propelled wheelchair short distances;-Independent transfer from wheelchair to bed;-Independent transfer from bed to wheelchair;-Independent bathroom privileges;-No period of incontinence;-Staff assistance with shower only to bring towels and turn water on. During an interview on 04/30/26 at 1:30 P.M., the resident said the following;-He/She was blind in one eye, had impaired vision in the other eye and only saw shadows and could not see fine details;-He/She was independent with eating, transferring, going to the bathroom, wheeling short distances and doing his/her own hygiene/shower after staff turned on the water and brought him/her towels and a washcloth;-He/She rarely had a urine or bowel accident. 3. Review of Resident #10's face sheet showed a diagnosis of schizoaffective disorder, bipolar type (a mental health condition that includes features of both schizophrenia and a mood disorder). Review of the resident's annual MDS, dated [DATE], showed the resident had a diagnosis of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). The diagnosis triggered an MDS indicator for no Pre-admission Screening and Resident Review (PASARR - a screening assessment used to determine if a resident is suitable for residence in a long-term care facility) and for medication use with a diagnosis of schizophrenia. Review of the resident's medical record showed no documentation the resident had a diagnosis of schizophrenia. 4. During an interview on 04/30/2026 at 3:41 P.M., the MDS coordinator said the following;-Currently, she worked offsite and had not been to the facility;-She just took over the facility's MDSs and planned to go to the facility soon;-A new diagnosis for schizophrenia should be verified before adding it to the MDS;-Staff should include falls and wounds on the MDS if they were present during the look-back period;-Resident #2's MDS should have reflected falls and pressure ulcers if they were present during the look-back period;-She did not complete the MDSs for the residents identified in the citation. During an interview on 04/30/26 at 2:50 P.M., the Administrator said the following:-She expected the MDS to be accurate;-She expected staff to code the MDS according to the RAI manual;-Staff should accurately code wounds and falls on the MDS;-Resident #10 had a diagnosis of schizoaffective disorder and did not have a diagnosis of schizophrenia. Staff incorrectly marked the schizophrenia diagnosis on the MDS.

Based on observation, record review, and interview, the facility failed to develop a comprehensive, person-centered care plan for four residents (Residents #71, #79, #105, and #2), in a review of 30 sampled residents, when staff did not develop a care plan to address pertinent care areas, including pain, a pressure ulcer, smoking, and a urinary catheter. The facility census was 116. Review of the facility policy, Comprehensive Care Plans, revised 10/31/24, showed the following:-It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment;-The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed;-The comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;-The interdisciplinary team (IDT) will prepare comprehensive care plans;-The IDT will review and revise the comprehensive care plan after each comprehensive and quarterly MDS assessment;-The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed;-Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 1. Review of Resident #71's face sheet showed the resident's diagnoses included chest pain, cervical (neck) radiculopathy (a pinched nerve causing compression or irritation of nerve roots, resulting in pain, numbness, tingling, or weakness), pain in joints of left hand, low back pain, and other chronic pain. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/23/26, showed the following:-The resident did not receive scheduled pain medications;-The resident did receive as needed pain medications;-The resident did not receive non-medication interventions for pain;-The resident received an opioid medication. Review of the resident's April 2026 physician order sheet (POS), showed the following:-Assess for pain every shift;-Biofreeze gel (a topical pain reliever) 4%, apply to lower back/hips topically every four hours as needed for pain;-Tylenol (a medication to relieve pain and reduce temperature) 325 mg, give two tablets by mouth every six hours as need for pain and/or temperature;-Norco (a narcotic pain medication) 7.5-325 mg, give one tablet every six hours as needed for pain;-Consult pain management for low back pain;-Refer resident to pain clinic. Review of the resident's medication administration record (MAR), dated April 2026, showed the following:-The resident received 10 doses of as needed Tylenol;-The resident received four doses of as needed Biofreeze;-The resident received 59 doses of as needed Norco. Review of the resident's progress notes, dated 4/26/26 at 11:02 A.M., showed staff administered Norco. Review of the resident's progress notes, dated 4/26/26 at 1:27 P.M., showed the Norco administration was effective. The resident's follow up pain score was a 3 (on a scale of 1-10 with 10 being the most pain). During an interview on 4/26/26 at 3:16 P.M., the resident said he/she was in pain, and his/her chest was hurting. Review of the resident's progress notes, dated 4/27/26 at 6:39 A.M., showed staff administered Norco for a complaint of back pain. Review of the resident's progress notes, dated 4/27/26 at 5:04 P.M., showed staff administered Norco. Review of the resident's progress notes, dated 4/27/26 at 6:32 P.M., showed the Norco administration was effective with a follow up pain score of 0 (no pain). During an interview on 4/27/26 at 6:56 P.M., the resident said he/she was in pain. Review of the resident's progress notes, dated 4/27/26 at 10:36 P.M., showed the resident had complaints of chronic back pain and received Norco, Tylenol, and Biofreeze as requested. During an interview on 4/28/26 at 2:35 P.M., the resident said the following:-His/Her back hurt;-He/She had chronic back pain, but it had been worsening;-He/She received pain medications, but the medications did not seem to work as well. Observation on 4/29/26 at 10:35 A.M. showed the resident walking the hallway and told Licensed Practical Nurse (LPN) F he/she would like a pain pill. Review of the resident's current care plan, dated 3/13/26, showed no documentation the resident had pain, used narcotic pain medications, and no interventions to address the resident's pain. 2. Review of Resident #79's face sheet showed the following:-He/She was his/her own responsible party;-Diagnoses included nicotine dependence. Review of the resident's admission MDS, dated [DATE], showed the following:-Cognitively intact;-No impairment in range of motion to his/her upper extremities;-The resident required maximum assistance for eating;-No tobacco usage. Review of the resident's Smoking and Safety Assessment, dated 4/09/26, showed the following:-The assessment will be utilized for the resident's smoking care plan on admission and as indicated;-The resident used tobacco products;-The resident showed the following: limited or no range of motion (ROM) in arms or hands, insufficient fine motor skills needed to securely hold tobacco or other smoking item, follows the facility's policy on location and time of smoking;-The resident showed the following safety concerns: unable to light tobacco or other smoking products safely, unable to hold tobacco or other smoking products safely, unable to extinguish tobacco or other smoking products safely, unable to use ashtray to extinguish tobacco or other smoking products;-The resident determined today that he/she is going to begin smoking;-The care planning section for tobacco use was left blank;-The clinical suggestions section was left blank. During an interview on 4/27/26 at 5:50 P.M., the resident said the following:-He/She smoked occasionally;-He/She was made to wear a smoking apron yesterday and today, but has not worn one prior;-He/She had neuropathy in their hands. Review of the resident's care plan, dated 3/27/26, showed no documentation the resident smoked, no smoking interventions, or smoking safety concerns as identified on the resident's smoking assessment. 3. Review of Resident #105's annual MDS, dated [DATE], showed the following:-Cognitively intact;-No bladder appliances;-Always continent of bladder. Observation on 4/26/26 at 12:32 P.M. showed the resident had a catheter drainage bag, which contained clear yellow urine, hooked to his/her wheeled walker. During an interview on 4/26/26 at 3:10 P.M., the resident said the following:-He/She had a new catheter placed two days ago while at the hospital due to urine retention;-He/She was told the catheter would stay in place for one to two weeks, then he/she would follow up with urology. Review of the resident's urology consult note, dated 4/28/26, showed the following:-The resident had a catheter in place due to urinary retention;-The resident had possible diabetic cytopathy (a common complications of long-standing diabetes, causing nerve damage that affects bladder control) with recently placed catheter and noted hydronephrosis (swelling of the kidneys caused by a buildup of urine that cannot be drained properly);-The resident was scheduled for urodynamics (a test that evaluates how well the bladder stores and releases urine) and a renal ultrasound;-Order to change catheter monthly. During an interview on 4/29/26 at 9:40 A.M., the resident said he/she saw urology yesterday and he/she still had the catheter. Review of the resident's care plan showed no documentation the resident had a urinary catheter. 4. Review of Resident #2's care plan, revised 7/20/23, showed the following:-He/She had actual skin impairment to skin integrity related to psoriasis (a chronic autoimmune skin disease);-Educate resident/family/caregivers of causative factors and measures to prevent skin injury;-Identify/document potential causative factors and eliminate/resolve where possible. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident was not at risk of developing pressure ulcers;-No unhealed pressure ulcers. Review of the resident's skin issues assessment, dated 2/03/26, showed a new stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough, may also present as an intact or open/ruptured blister), in-house acquired, located on the intergluteal cleft (the groove between the buttocks). Review of the resident's care plan showed no documentation staff updated the care plan to include the resident's pressure ulcer. Review of the resident's physician orders, dated 2/10/26, showed an order to apply gauze to the gluteal cleft after cleansing with soap and water or wound cleanser, one time a day for wound care. Review of the resident's quarterly MDS, dated [DATE], showed no unhealed pressure ulcers. Review of the resident's physician orders, dated 3/11/26, showed an order to discontinue applying gauze to the gluteal cleft after cleansing with soap and water or wound cleanser, one time a day for wound care. 5. During an interview on 04/30/26 at 2:50 P.M., the Administrator said the following:-The Interdisciplinary Team (IDT) was responsible for completing and updating the care plans at each risk management meeting;-The care plan should be accurate and show the most current level of care for each resident. During an interview on 04/30/26 at 3:41 P.M., the MDS Coordinator said the following:-She just recently took over completing the MDSs for this facility;-She had not been on-site at the facility since taking on this role;-She was responsible for completing the new admission and annual care plans, but she did not know if the facility had a corporate care plan coordinator;-If the facility did not have a corporate care plan coordinator, the facility was responsible for updating the care plans.

Based on observation, interview, and record review, the facility failed to update and revise resident care plans to accurately reflect current care needs for five residents (Residents #10, #13, #70, #2 and #79), in a review of 30 sampled residents. The facility census was 116. Review of the facility's policy, Comprehensive Care Plans, revised on [DATE], showed the following: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment;-The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment;-The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed;-The Individualized Care Service Plan (ICSP), (also called the bedside care plan) will be updated with pertinent information needed for nursing staff on the floor to provide the needed care for residents. 1. Review of Resident #10's annual Minimum Data Set (MDS), a mandatory assessment instrument completed by facility staff, dated [DATE], showed the following:-Cognitively intact;-No hearing or vision issues, made self understood, and understood others;-Required partial/moderate assist of one staff for upper and lower body dressing and putting on/taking off footwear, bathing and personal hygiene;-Supervision or touch assistance only for oral care. Review of the resident's care plan, revised on [DATE], showed the following: -The facility will follow the resident's advanced directive for code status, initiated [DATE]. The resident was a full code (if someone's heart stops beating or they stop breathing, medical staff will use all life-saving measures to resuscitate them, to include cardio-pulmonary resuscitation (CPR);-Risk for impaired communication, initiated on [DATE]. The resident will be able to effectively communicate basic needs; -Intake more than body requirements, initiated on [DATE]. The resident was on a regular diet with large portions;-The resident was on a regular diet, initiated [DATE];-The resident had an activity of daily living (ADL) self-care deficit, initiated on [DATE], and was totally dependent on one staff for dressing, personal hygiene and oral care. Review of the resident's [DATE] physician order sheet (POS) showed the following:-Regular diet, regular texture, thin/regular consistency, large portions, house supplement three times a day with meals with an order date of [DATE];-Code status was DNR (Do Not Resuscitate, indicating CPR would not be started in the event the resident was without pulse or respirations) with an order date of [DATE]. Observation on [DATE], at 2:15 P.M., showed an emergency cart, located inside nursing station one, included a list of residents whose code status was DNR and signed physician orders for DNR status. The resident's name was included on the list with a physician signed Out-of-Hospital purple sheet which indicated the resident was DNR status. During an interview on [DATE], at 11:35 A.M., the resident said the following: -He/She was able to make his/her needs known verbally and could understand staff when they asked questions;-He/She needed assistance of one staff for things like dressing and transfers. He/She was able to assist with dressing and transfers, and staff did not have to do it all;-He/She did not want CPR performed if his/her heart or lungs stopped working and was a DNR. Review of the resident's care plan showed staff failed to update the plan to accurately reflect the resident's code status, diet order, activities of daily living (ADLs) assistance needs and communication status. 2. Review of Resident #13's care plan, revised [DATE], showed the following: -He/She was on a regular diet, initiated [DATE];-The facility will follow the resident's advanced directive for code status. The resident was a full code, initiated [DATE].-Terminal illness related to end of life status, as evidenced by hospice enrollment and progressive decline, initiated [DATE]. Review of the resident's POS, dated [DATE], showed the following: -Regular diet, mechanical soft with ground meat texture, thin consistency, use condiments to moisten, ketchup/BBQ sauce, gravy, etc., with an order date of [DATE];-Code status: DNR with an order date of [DATE]. Observation on [DATE], at 2:15 P.M., showed an emergency cart inside nursing station one that included the DNR list and signed physician orders for DNR. The resident's name was included on that list with a physician signed Out-of-Hospital purple sheet which indicated DNR status. Review of the resident's care plan showed staff failed to update the plan to accurately reflect the resident's code status and diet order. 3. Review of Resident #70's undated face sheet showed the resident was his/her own responsible part. The resident's code status was DNR. Review of the resident's care plan, revised [DATE], showed the following: -The resident had a guardian to assist in decision making due to mental illness, initiated [DATE];-The facility would follow the resident's advanced directives for code status. He/She was a full code, initiated [DATE]. Review of the resident's POS, dated [DATE], showed the resident's code status was DNR. Observation on [DATE] at 2:15 P.M., showed an emergency cart, located inside nursing station one, included a list of residents whose code status was DNR and signed physician orders for DNR status. The resident's name was included on the list with a physician signed Out-of-Hospital purple sheet which indicated the resident was DNR status. During an interview on [DATE], at 1:54 P.M., the resident said he/she was his/her own responsible party and decision maker. He/She did not have a guardian. He/She did not want CPR if his/her heart and lungs stopped working. Review of the resident's care plan showed staff failed to update the plan to accurately reflect the appropriate responsible party and the resident's code status. 4. Review of Resident #2's undated face sheet showed the resident's diagnoses included muscle weakness, unsteadiness on feet, other abnormality of gait and mobility, lack of coordination, and repeated falls. Review of the resident's care plan, dated [DATE], showed the following:-The resident was at low risk for falls related to psychoactive drug use;-Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs;-Follow facility fall protocol;-Pharmacist review of medication;-Resident reeducated on situational awareness. Review of the resident's care plan, revised [DATE], showed the following:-The resident had poor safety awareness related to refusing to use a walker or walking away from it;-Encourage use of prescribed assistive devices;-Safety measures, including strategies to reduce the risk of falls and injury, initiated as appropriate. Review of the resident's progress note, dated [DATE] at 3:42 A.M., showed staff found the resident on the floor of his/her room, lying next to the bed on his/her stomach. Review of the resident's progress note, dated [DATE] at 3:10 P.M., showed staff witnessed the resident fall to the floor and land on his/her buttocks. The resident leaned to the left with both legs bent to the right under his/her upper thighs. Review of the resident's progress note, dated [DATE] at 7:55 A.M., showed the resident fell out of his/her wheelchair onto the floor and hit his/her head. Review of the resident's care plan showed the care plan for falls was marked as resolved on [DATE] and there was no active care plan to address falls or fall interventions. Staff did not update or revise the plan of care following the resident's falls on [DATE], [DATE] and [DATE]. Review of the resident's progress note, dated [DATE] at 10:47 A.M., showed staff found the resident on the fall mat on the floor beside his/her bed. Review of the resident's progress note, dated [DATE] at 8:45 A.M., showed staff witnessed the resident fall and hit the left side of his/her face on the floor. Review of the resident's progress note, dated [DATE] at 2:35 P.M., showed staff found the resident on his/her stomach on the fall mat with blankets under him/her. Review of the resident's progress note, dated [DATE] at 2:32 P.M., showed staff found the resident on the fall mat by the bed with covers under him/her. Review of the resident's progress note, dated [DATE] at 2:41 P.M., showed staff found the resident on the fall mat on the floor, resting on his/her left side, with covers underneath him/her. Review of the resident's progress note, dated [DATE] at 7:30 P.M., showed staff found the resident face down on his/her floor by the bed. His/Her legs were on the fall mat but his/her top half of body was on the bare floor. Review of the resident's progress note, dated [DATE] at 7:30 P.M., showed staff found the resident on his/her bedroom floor, face down on the fall mat beside the bed with both arms under his/her chest. During an interview on [DATE] at 6:36 P.M., the resident said he/she was at risk for falls, which is why there was a mat on the floor beside his/her bed. During an interview on [DATE] at 9:36 A.M. and 4:15 P.M., Nurse Aid (NA) S said the resident was a fall risk and had a low bed, fall mat, call light in reach, required 15-minute face checks, and required frequent reminders to use the call light as interventions to prevent falls. During an interview on [DATE] at 4:21 A.M., Licensed Practical Nurse (LPN) U said the resident had a period of time where he/she had multiple falls and was very non-compliant with interventions and education. Review of the resident's care plan showed staff did not update or revise the care plan to address the resident's fall risk and continued falls on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] as well as the interventions put in place to prevent falls, including the fall mat, low bed, and 15 minute checks. 5. Review of Resident #79's undated face sheet showed he/she was his/her own guardian. The resident's diagnoses included lack of coordination, need for assistance with personal cares, muscle weakness, displaced (not in alignment) intertrochanteric fracture of the right femur (upper hip). Review of the resident's care plan, updated [DATE], showed the following:-The resident had an activity of daily living (ADL) self-care performance deficit related to activity intolerance, impaired balance, and limited mobility and fracture of his/her leg;-The resident required assistance from one staff for toileting and to move between surfaces. Review of the resident's progress note, dated [DATE] at 6:30 P.M., showed the resident arrived at the facility in a manual wheelchair. Two staff assisted the resident into bed. Review of the resident's progress note, dated [DATE] at 5:06 A.M., showed the resident required assistance from two staff for activities of daily living (ADLs) and was non-weight bearing on the right leg. Review of the resident's progress note, dated [DATE] at 10:06 A.M., showed the resident required assistance from two staff for all cares and required a hoyer lift (mechanical lift) for transfers. Review of the resident's orthopedic consult note, dated [DATE], showed the following:-Continue therapy as ordered;-Weight bearing as tolerated to the right lower extremity, no restrictions. Observation on [DATE] at 2:37 P.M. showed Nursing Assistant (NA) E, NA S and NA T transferred the resident from his/her wheelchair to the bed with a hoyer lift. During an interview on [DATE] at 4:02 P.M., the Therapy Director said the following:-Orthopedics cleared the resident for weight-bearing as tolerated;-The resident remained a hoyer lift for non-therapy staff due to the resident's fear and neuropathy. During an interview on [DATE] at 4:15 P.M., NA S said the resident used a hoyer lift to transfer. During an interview on [DATE] at 4:21 P.M., Licensed Practical Nurse (LPN) U said the resident was cleared for weight-bearing as tolerated, but therapy had not released him/her, so he/she still transferred with a hoyer lift. Review of the resident's care plan showed staff did not update the plan to adequately reflect the resident's transfer status. 6. During an interview on [DATE], at 2:50 P.M., the Administrator said the following: -The Interdisciplinary Team (IDT) was responsible for completing and updating the care plans at each risk management meeting;-She updated the resident care plans during that meeting;-The care plan should be accurate and show the most current level of care for each resident;-The facility did not have a specific care plan coordinator;-A staff member from corporate had been updating care plans and seemed to be resolving issues that were still current;-The staff member from corporate was not helping with care plan updates anymore.

Based on observation, interview, and record review, the facility failed to accurately complete an assessment to identify the history of trauma, the presence of symptoms related to the trauma, and triggers that may cause re-traumatization and to develop an individualized care plan with interventions to mitigate and eliminate these triggers for three residents (Residents #88, #6 and #23), in a review of 30 sampled residents. The facility census was 116. Review of the facility policy, Trauma Informed Care, revised 05/14/24, showed the following:-It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization;-Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. Common sources of trauma may include, but are not limited to natural and human caused disasters; accidents; war; physical, sexual, mental, and/or emotional abuse (past or present); rape; violent crime; history of imprisonment; history of homelessness; traumatic life events (death of a loved one, personal illness, etc.);- Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization;-The facility will work to facilitate the principles of trauma informed care which include: A. Safety ensuring residents have a sense of emotional and physical safety; B. Trustworthiness and transparency Efforts to establish a relationship based on trust, and clear and open communication between the staff and the resident; C. Peer support and mutual self-help - If practicable, assist the resident in locating and arranging to attend support groups (potentially hosted by the facility) which are organized by qualified professionals; D. Collaboration is an emphasis on partnering between residents and/or his/her representative, and all staff and disciplines involved in the resident's care in developing the plan of care; E. Empowerment, voice and choice - Ensuring resident's choice and preferences are honored and that residents are empowered to be active participants in their care and decision-making, including recognition of, and building on resident's strengths;-The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his/her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others;-The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions;-In some cases, if the facility has more than one trauma survivor, social services will make a good faith effort at establishing a support group that is run by a qualified professional or allow a support group to meet in the facility. If a group cannot be run/meet at facility, social services will assist the resident in locating a support group in the community as appropriate and feasible;-The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. While most triggers are highly individualized, some common triggers may include, but are not limited to: A. Experiencing a lack of privacy or confinement in a crowded or small space; B. Exposure to loud noises, or bright/flashing lights; C. Certain sights, such as objects that are associated with their abuser; D. Sounds, smells, and physical touch;-Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery;-The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization. The resident and/or his or her family or representative will be included in this evaluation to ensure clear and open discussion and better understand if interventions must be modified;-In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. 1. Review of Resident #23's Level II Preadmission Screening and Resident Review (PASRR, a screening for serious mental illness, intellectual disability, developmental disability or related conditions that ensures appropriate placement and ensures one receives the necessary specialized services identified)/Level II Evaluations, dated 1/27/25, showed the following:-Diagnoses included post-traumatic stress disorder (PTSD, mental health condition triggered by experiencing or witnessing terrifying events) with nightmare disorder, bipolar disorder (mood disorder that can cause intense mood swings) severe with psychotic features, major depressive disorder, traumatic brain injury (TBI, a disruption in normal brain function caused by an external physical force or a penetrating injury) at age [AGE], dissociative disorder (mental health conditions characterized by an involuntary disconnection between thoughts, memory, identity, or consciousness), mild intellectual disability, borderline personality disorder with psychosis (intense emotional instability combined with short-lived, stress-induced breaks from reality), and personality disorder.-The resident states his/her siblings beat him/her causing 30 percent memory loss;-Onset of psychiatric issues around age [AGE] after a head injury;-History of multiple suicide attempts, anxiety, sadness, confusion, decreased appetite, sleep disturbance, mood swings, hyperactivity, agitation, suspicious, combative behaviors, psychosis and aggression. Impulsive, verbal outburst, command hallucinations, labile, delusional, impulse, depression, problems with concentration, irritability and isolation;-Jailed for hitting people-Crisis intervention: The resident requires a plan to address harm to self or others. Plan should identify clear steps that will be taken to support individual during a crisis situation, specify who to contact for assistance, how staff should work together with individual during the crisis, as well as identify when the physician, emergency medical services and/or law enforcement should be contacted. Review of the resident's care plan, dated 11/04/25, showed the following:-History of PTSD;-PTSD affects resident symptoms and may flare up without any known trigger;-Functional impairment from symptoms, negative alterations in mood and cognitions that began or got worse after the initial event;-Must include two of the following: Inability to recall key features of the event, persistent or negative beliefs, persistent distorted blame, persistent negative emotions, significant lack of interest, feeling of alienation, inability to experience positive emotions;-Goal: The resident will be able to identify triggers and will learn and utilize positive coping strategies. The resident will demonstrate control of emotions and relaxation techniques;-Administer medications appropriately and monitor for side effects or dependance;-Assess anxiety level, determine severity of condition and course of treatment or therapy needs;-Assess resident for suicidal or homicidal ideations to ensure safety of the resident and others;-Assess vitals and assess resident;-Determine baseline for vitals and assess for underlying or accompanying medical conditions;-Encourage the resident to express emotions in a safe environment-Allow residents the freedom to acknowledge their feelings and release any repressed emotions that may be exacerbating their distress. A safe environment should be free from actual or perceived judgement and physical or perceived danger.-Encourage the resident to keep a journal of stressors and emotional reactions to those stressors-Help the resident identify triggers that prompt anxiety or symptoms and evaluate the outcomes of those reactions;-Encourage the resident to verbally identify current ineffective coping techniques. Help the resident understand his/her current behaviors that may be preventing effective healing or treatment.(The resident's care plan did not include the type of trauma the resident experienced or specific triggers for the resident.) Review of the resident's quarterly Minimum Data Set (MDS), dated [DATE], showed the following:-Cognitively intact;-Moderate depressive symptoms;-No hallucinations, delusions, or behaviors;-Diagnoses included traumatic brain injury, anxiety disorder, depression, bipolar, schizophrenia, PTSD, impulse disorder, and dysthymic disorder (long term depression);-Medications include antipsychotic, antianxiety, and antidepressant. Review of the resident's Trauma Informed Care Assessment, dated 04/22/26, showed the resident did not experience trauma in the last quarter. (Review of the resident's medical record showed no documentation staff completed a Trauma Informed Care Assessment between admission and 04/22/26.) Observation on 04/30/26 at approximately 9:30 P.M., showed the facility tested the fire alarm. The fire alarm was loud throughout the building. Observation on 04/30/26 at 3:30 P.M. showed the resident sitting in a chair in his/her room. The lights in the room were turned off. During an interview on 04/30/26, at 3:30 P.M., the resident said the following:-He/She had PTSD;-He/She had multiple traumas in his/her life including a bad bike wreck with a head injury, his/her grandparent passed away, abuse by family members, and he/she was injured after an IED exploded while he/she was in the military;-Loud noises like the fire alarm, doors slamming and people arguing and yelling were his/her triggers;-Today, the facility tested the fire alarm, and he/she didn't know it was going to go off. He/She was sitting in his/her room with the light off trying to calm down because the fire alarm triggered him/her;-The tornado siren made him/her feel paralyzed with fear; he/she felt like he/she could not move;-Arguing and yelling gave him/her anxiety;-Doors slamming made him/her feel like he/she needed to run away or get ready to fight someone;-He/She has bad nightmares and took medication to try to prevent the nightmares;-Staff do not do anything to try to prevent him/her from being triggered;-Staff do not warn him/her if they are testing the fire alarm or any other loud noises;-He/She thought they did not warn him/her because they do not care if it triggered anyone;-If he/she knew there was going to be an alarm or a loud noise, he/she could prepare mentally for it so he/she would not be so scared. It takes him/her a long time to calm down. 2. Review of Resident #88's PASRR/Level II Evaluations, completed on 08/26/25, showed the following:-Diagnoses of bipolar disorder, schizoaffective disorder (mental health condition that includes features of both schizophrenia and a mood disorder), PTSD, antisocial personality disorder (mental health condition characterized by a lack of regard or remorse for others), psychosis (mental health condition characterized by a disconnection from reality), and substance abuse;-Plan to identify clear steps that will be taken to support individual during crisis. Specify who to contact for assistance, how staff will work together with the individual during a crisis, as well as identify when the physician, emergency medical services, and /or law enforcement will be contacted. Review of the resident's Trauma Informed Care Screen/Assessment, dated 04/24/25, showed the following:-The resident has not experienced a natural disaster, fire/explosion, transportation accident, serious accident, exposure to toxic substances, physical assault, assault with a weapon, sexual assault, combat/war zone, captivity, life-threatening illness/injury; sudden violent death of someone close to you, accidental death of someone close to you; serious injury, harm or death you caused to someone else;-Staff did not identify any symptoms or possible triggers or interventions. Review of the resident's Trauma Informed Care Screen/Assessment, dated 08/27/25, showed the following:-The resident has not experienced a natural disaster, fire/explosion, transportation accident, serious accident, exposure to toxic substances, physical assault, assault with a weapon, sexual assault, combat/war zone, captivity, life-threatening illness/injury; sudden violent death of someone close to you, accidental death of someone close to you; serious injury, harm or death you caused to someone else;-Staff did not identify any symptoms or possible triggers or interventions. Review of the resident's Trauma Informed Care Screen/Assessment, dated 02/10/26, showed the following:-The resident has not experienced a natural disaster, fire/explosion, transportation accident, serious accident, exposure to toxic substances, physical assault, assault with a weapon, sexual assault, combat/war zone, captivity, life-threatening illness/injury; sudden violent death of someone close to you, accidental death of someone close to you; serious injury, harm or death you caused to someone else;-Staff did not identify any symptoms or possible triggers or interventions. Review of the resident's care plan, dated 03/17/26, showed the following:-The resident has a history of behavioral challenges that require protective oversight in a secure setting;-Implement plans to change inappropriate behavior- behavior management plan;-Non-pharmaceutical interventions: One-on-one interventions as needed;-Pharmaceutical interventions as needed.(The resident's care plan did not address the resident's diagnosis of PTSD, triggers or interventions to address or prevent re-traumatization.) Review of the resident's comprehensive MDS, dated [DATE], showed the following:-Cognitively intact;-Moderate depression symptoms;-No hallucinations, delusions, or behaviors;-Diagnoses include schizoaffective disorder, hypertension, anxiety and schizophrenia. During an interview on 04/30/26, at 3:50 P.M., the resident said the following:-He/She had traumatic things happen in his/her life;-When he/she was eight years old, he/she saw his/her family member die of a drug overdose. It was scary and awful to witness;-He/She has been bullied, spit on and some worse things he/she didn't want to talk about;- It's hard to think there are children being molested right now as we speak (The resident did not respond when asked if this happened to him/her or someone who was close to him/her. The resident's eyes were teary and his/her voice quivered);-He/She was triggered when he/she felt like someone was trying to manipulate him/her or when they went back on their word;-When he/she tried to meet goals, and the goal post moved farther away, it triggered him/her, and he/she went into fight or flight mode;-It also triggered him/her when people were dishonest or tried to get him/her into trouble. It brought feelings of betrayal to the forefront;- Smoking weed helped him/her stay calm;-He/She was in a drug rehabilitation facility in the past that had physical jobs and responsibilities for everyone;-It was the most peaceful time in his/her life. He/She felt worthy and in control of his/her day-to-day life;-During that time, he/she had jobs like cutting wood or working outside, and it was good for his/her soul;-He/She thought he/she would do better if he/she had goals and felt some self-worth, like a job or something he/she was responsible for and could take pride in; -He/She felt attending real church services would be nice. He/She stayed more grounded when he/she could pray in a structured environment. 3. Review of Resident #6's care plan, dated 11/27/24, showed the following:-The resident had a history of PTSD;-PTSD affected the resident's symptoms and may flare up without any known trigger;-Alterations in reactivity from the traumatic event including aggressiveness and self-destructive behavior, negative alterations in mood and cognitions that began or got worse after the initial event;-Goal: The resident will be able to identify triggers, utilize positive coping strategies and demonstrate control of emotions and relaxation techniques;-Administer medications appropriately and monitor for side effects or dependance;-Assess anxiety level and determine severity of condition and course of treatment or therapy needs;-Encourage the resident to express emotions in a safe environment;-Allow the resident the freedom to acknowledge his/her feelings and release any repressed emotions that may be exacerbating his/her distress;-A safe environment should be free from actual or perceived judgement and physical or perceived danger;-Establish trust with the resident. Listen to what the resident is saying. Behave in a calmmanner;-Establishing trust can help the client calm down and make treatment more effective;-Provide calming and reassuring environment;-Residents with PTSD are often fearful. Provide a calm, relaxing environment can help lessen or relieve anxiety and promote a feeling of safety. Review of the resident's PASRR/ Level II Evaluations, dated 1/27/25, showed the following:-Diagnoses include major depressive disorder, personality disorder (mental health condition characterized by rigid, long-term patterns of thoughts, emotions, and behaviors that differ significantly from cultural expectations), bipolar disorder, generalized anxiety disorder, opioid dependence, PTSD, schizoaffective disorder (mental health condition that includes features of both schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) and a mood disorder) and attention-deficit hyperactivity disorder (ADHD, a condition characterized by persistent patterns of inattention, hyperactivity, impulsivity that interfere with daily functioning);-History dates back to 2009 with a diagnosis of bipolar disorder, symptoms have included suicidal ideations, mood lability, increased depression, anxiety, racing thoughts, impulsivity, irritability, distractibility, risk taking behaviors, and manic episodes;-Plan to identify clear steps that will be taken to support individual during crisis, specify who to contact for assistance, how staff will work together with the individual during a crisis, as well as identify when the physician, emergency medical services, and /or law enforcement will be contacted. Review of the resident's Trauma Informed Care Screen/Assessment, dated 06/10/25, showed the following:-Information from the resident;-The resident has not experienced a natural disaster, fire/explosion, transportation accident, serious accident, exposure to toxic substances, physical assault, assault with a weapon, sexual assault, combat/war zone, captivity, life-threatening illness/injury; sudden violent death of someone close to him/her, accidental death of someone close to him/her; serious injury, harm or death he/she caused to someone else;-Staff did not identify any symptoms or possible triggers or interventions. Review of the resident's care plan, dated 08/18/25, showed on 08/18/25, the resident believed he/she heard a motorcycle and thought it was his/her ex coming to get him/her. He/She broke the window in his/her room and went out into the fenced area. He/She then saw it was the lawnmower, and he/she came back into the building and let staff know. Review of the resident's Trauma Informed Care Screen/Assessment, dated 09/10/25, showed the following:-Information from the resident;-The resident has not experienced a natural disaster, fire/explosion, transportation accident, serious accident, exposure to toxic substances, physical assault, assault with a weapon, sexual assault, combat/war zone, captivity, life-threatening illness/injury; sudden violent death of someone close to him/her, accidental death of someone close to him/her; serious injury, harm or death he/she caused to someone else;-Staff did not identify any symptoms or possible triggers or interventions. Review of the resident's care plan, dated 12/04/25, showed the following:-The resident's safety plan with his/her personal goal to go home:-Past crisis moments include rape and drug use.(The resident's care plan did not list any triggers for the resident or direction to staff on how to prevent triggering or re-traumatization of the resident.) Review of the resident's Care Plan, updated 03/05/26, showed the resident had a psychosocial well-being problem related to anxiety and PTSD from past relationships. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Moderate depression symptoms;-No hallucinations, delusions, or behaviors;-Diagnoses included anxiety, depression, bipolar, schizophrenia, and PTSD. During an interview on 04/26/26 at 11:19 A.M., the resident said he/she had severe PTSD. People of the opposite sex are one of his/her triggers. When people of the opposite sex yell or fight, it triggers him/her. He/She wants to get involved and help; he/she has a [NAME] complex but then he/she ends up getting hurt;-He/She has experienced a lot of trauma;-He/She broke out his/her window when he/she was triggered because he/she thought someone was after him/her. During an interview on 04/30/26 at 4:25 P.M., the Administrator said the resident had an episode on 4/30/26 when he/she came to the dining room naked, wrapped in a blanket, and would not speak. He/She was sent to the psychiatric hospital for evaluation. During an interview on 04/30/26, at 4:40 P.M., Certified Nurse Assistant (CNA H) said the resident was sleeping most of the morning, then he/she was in the bathroom a lot. The resident came to the dining room naked wrapped in a blanket and would not speak or respond to staff, so they sent him/her out on 04/30/26. During an interview on 05/05/26 at 2:52 P.M., the resident's guardian's deputy said the following:-The resident was sent to the hospital on [DATE];-He/She was not sure what triggered the resident;-PTSD was on the resident's PASRR but he/she did not know the specifics;-The resident was triggered often and could become violent;-The resident had several violent behaviors and destroyed property when he/she had outburst;-In August, he/she knocked out the window in his/her room and climbed out because he/she thought he/she heard a motorcycle and thought he/she was in danger. The resident went back into the facility when he/she saw the sound came from the lawn [NAME]. 4. During an interview on 04/30/26, at 4:08 P.M., Certified Nurse Assistant (CNA) H said he/she was not sure which residents had PTSD. During an interview on 04/30/26, at 4:12 P.M., Certified Medication Technician (CMT) B said the following:-He/She was the team lead, often, on Station II (locked behavioral unit;-He/She knew Resident #6 had PTSD, but he/she was not sure of the specifics;-There were many residents on Station II who most likely had PTSD;-He/She did not know of any specific triggers for the residents with PTSD;-If he/she had questions, he/she would look at the resident's care plan. During an interview on 04/30/26 at 2:50 P.M., the Administrator said the following:-Staff complete a Trauma Informed Care Assessment for resident with PTSD;-She or the Social Services Director completed the initial Trauma Informed Care Assessments;-She completed the Trauma Informed Care Assessment from the information provided on the residents' PASRR. If the PASRR did not include the specific trauma or triggers, then they may not know them;-She did not interview the residents when completing the assessment;-The staff had not been instructed to call the guardians for information about the residents' traumas.-She was not aware the fire alarm triggered Resident #23;-The facility could not prevent sounding the fire alarm or tell residents in advance staff were sounding the fire alarm because it would make the fire drill useless;-Ideally, the facility would know what caused the residents' trauma and what the residents' triggers were so they were on the care plan for staff to know what to be aware of for each resident.

Based on observation, interview, and record review, the facility failed to ensure four nurse aides completed a nurse aide (NA) training program within four months of their employment in the facility. The census was 116. Review of the facility's policy, Nurse Aide Training Program, revised 05/18/24, showed the following:-Purpose: This facility maintains an appropriate and effective nurse aide in-service training program for the purpose of ensuring the continuing competence of nurse aides;-The facility, with oversight from the Director of Nursing, shall be responsible for the coordination and/or provision of nurse aide education. Review of the facility's' undated Hospitality Aide Duties, showed the following:-Purpose: The Hospitality Aide position is a way to ensure there is extra support within the facility to help assist with non-nursing duties. To help ensure proper and effective guidelines for the role and tasks of all Hospitality Aides:-Walking rounds;-Intensive monitoring (frequent checks and one-on-one monitoring);-Assisting with smoking breaks for residents;-Cleaning of facility/resident equipment;-Assist with transportation of residents throughout unit, facility, or outings that do not require direct hands-on care;-Attend and assist with Code Greens (behavioral emergencies);-Assist with cardiopulmonary resuscitation (CPR, an emergency, life-saving technique used when a person's heartbeat or breathing has stopped) if the employee has proper certification;-Assist with activities (board games, puzzles, nail painting of residents);- Job Duties that the Hospitality Aides may not assist with on their assigned units include: -Direct patient care; -Bathing; -Dressing; -Grooming; -Turn and repositioning; -Feeding; -Hands on assistance of residents found on floor or witnessed falls; -Activities of Daily Living (ADL) Cares; -Peri-care (Perineal care (peri-care) - Care to the surface area between the thighs, extending from the pubic bone to tail bone.); -Catheter care (Indwelling - A sterile tube inserted into the bladder to drain urine); -Intake and output measuring/documenting (any food or drink intake and any urine output measuring or documenting for the resident). 1. Review of the facility nurse aide report showed NA E's date of hire, for the position of NA, was 02/10/25. Review of NA E's employee file showed no documentation NA E completed a nurse aide training program within four months of his/her hire date. Review of NA E's timecard on 04/29/26 at 3:02 P.M., showed he/she was a hospitality aide and was assigned to the direct care nursing department. During an interview on 04/29/26, at 4:20 P.M., NA E said the following:-He/She had been working as an NA for about a year and had been in classes since December 2025;-He/She would start testing on 05/09/26;-He/She worked as a hospitality aide at a different facility and knew the hospitality aide was not allowed to do any hands on work;-Since working at the facility, his/her title was NA and he/she provided daily care for the residents. Observation on 4/26/26 at 2:37 P.M. showed NA E assisted NA T and NA S to transfer a resident with a hoyer lift (a mechanical lift designed to safely transfer a resident with limited mobility). 2. Review of the facility nurse aide report showed NA X's date of hire, for the position of NA, was 08/01/25. Review of NA X's employee file showed no documentation NA X completed a nurse aide training program within four months of his/her hire date. During an interview on 05/08/26 at 8:30 P.M., NA X said the following:-He/She started working at the facility in August 2025 and was hired as a NA. He/She had never worked in another department and did not know what a hospitality aide was and no one from Human Resources told him/her he/she was a hospitality aide;-He/She started taking classes for certification as a CNA a couple of months ago;-He/She performed care for residents which included peri-care, catheter care, gait belt transfers and Hoyer lift transfers with another staff. 3. Review of the facility nurse aide report showed NA G's date of hire, for the position of NA, was 08/05/25. Review of NA G's employee file showed no documentation NA G completed a nurse aide training program within four months of his/her hire date. Observation on 04/29/26 at 1:25 P.M., showed the following:-NA G assisted Certified Nurse Assistant (CNA) C provide peri-care to Resident #48;-NA G assisted the resident to turn from his/her right side to left side to remove soiled clothing and linens;- NA G assisted the resident to take off his/her soiled shirt and assisted the resident to dress;-NA G used a gait belt and assisted the resident to stand During interviews on 04/29/26 at 3:59 P.M. and 05/06/26 at 9:55 A.M., NA G said he/she started working at the facility in August 2025 and was hired as a NA. He/She started taking nurse aide classes one to two months after he/she was hired but had not completed the course. No one told him/her she/he had four months to finish the nurse aide training program. Examples of some of the duties he/she performed included peri care, gait belt transfers, Hoyer lift transfers with other staff members, and resident showers. 4. During an interview on 04/29/26 at 3:20 P.M. and 05/08/26 at 8:01 A.M., Human Resources said the following:-She thought all the NA employees were considered NAs since their hire date. This information was listed on her NA spreadsheet. Corporate called them (the NAs) hospitality aides, but they were listed in the nursing direct care department;-When the facility hired an NA, the NA had 120 days to obtain a certified nurse assistant certification;-She was responsible for tracking the NA progression. She tracked the NA progression by writing their names and cutoff date on a whiteboard in her office. She logged into staffing development and checked the NAs class progression weekly;-If an NA had not completed their certification within four months, the NA was transferred out of the nursing department until they were certified;-She would not expect an NA to be in a position for more than four months without completing their certification. During interviews on 04/30/26 at 2:50 P.M. and 05/05/26 at 11:48 A.M., the Administrator said the following:-An NA was to complete their CNA certification within four months of hire. If they did not, they should be transferred to another department or terminated;-She only knew of one NA who had not completed his/her certification training;-Human Resources and administration were responsible to ensure an NA completed the certified training within four months of their hire date;-Hospitality aides would not provide hands on resident care. An NA was responsible for providing bathing, peri-care, transfers, etc.

Based on observation, interview, and record review, the facility failed to ensure discontinued and course completed medications, stored in the Station One medication storage room, were destroyed within 30 days according to the facility policy, for one resident (Resident #12), in a review of 30 sampled residents, and for three additional residents (Residents #37, #45 and #87). The facility census was 116. Review of the facility's Medication Destruction Policy, revised 6/26/24, showed the following:-Purpose: The purpose of this policy is to ensure medications that cannot be returned to the dispensing pharmacy are destroyed;-Medications should be destroyed weekly if possible but at a minimum of monthly;-The DON is responsible for ensuring that the medications that are no longer needed are being kept securely and destroyed properly. 1. Review of Resident #12's physicians order summary report, dated March 2026, showed the following:-An order, dated 03/02/26, to discontinue atorvastatin calcium (a cholesterol medication) 40 milligrams (mg), give two tablets via peg tube (g-tube, surgical insertion of a tube through the abdominal wall into the stomach) at bedtime. -An order, dated 03/02/26, to discontinue haloperidol (an antipsychotic medication) 5 mg, give one tablet via g-tube every six hours as needed for agitation or aggression for 14 days. -Ibuprofen (pain reliever) 600 mg, give one tablet via g-tube three times a day for right finger pain for three days. This medication was completed on 03/26/26. Observation on 04/28/26 at 4:16 P.M. showed the following medications, labeled for the resident, were stored in an upper cabinet in the Station One medication storage room:-Twenty-four atorvastatin calcium 40 mg tablets;-Twenty haloperidol 5 mg tablets;-Six ibuprofen 600 mg tablets.(Staff failed to destroy the medications within 30 days, per facility policy, after the medications were discontinued.) 2. Review of Resident #37's physician order, dated 12/04/25, showed an order to discontinue hydroxyzine pamoate (anti-anxiety medication) 25 mg, give one capsule at bedtime related to generalized anxiety disorder. Observation on 04/29/26 at 8:17 A.M., showed 21 capsules of hydroxyzine pamoate, labeled for the resident, were stored in the upper cabinet in the Station One medication storage room.(Staff failed to destroy the medication within 30 days, per facility policy, after the medication were discontinued.) 3. Review of Resident #45's physician order for December 2025 showed an order for hydroxyzine hydrochloric acid (HCL) 50 mg, give one tablet by mouth every six hours as needed for anxiety or agitation for 14 days. This medication was completed on 12/22/25. Review of the resident's physician orders for February 2026 showed an order for lactulose oral solution, give 30 milliliters (mL) by mouth every 24 hours as needed for constipation for 14 days. This medication was completed on 02/27/26. Observation on 04/29/26 at 8:17 A.M., showed the following medications, labeled for the resident, were stored in an upper cabinet in the Station One medication storage room:-Nine hydroxyzine hcl 50 mg tablets;-Approximately 328 ml lactulose oral solution.(Staff failed to destroy the medications within 30 days, per facility policy, after the medications were discontinued.) 4. Review of Resident #84's physician order for February 2026 showed an order for hydroxyzine hydrochloric acid (HCL) 50 mg, give one tablet every 24 hours as needed for anxiety or sleep for 14 days. This medication was completed on 02/13/26. Observation on 04/29/26 at 8:17 A.M., showed 11 tablets of hydroxyzine hcl 50 mg, labeled for the resident, were stored in the upper cabinet in the Station One medication storage room.(Staff failed to destroy the medication within 30 days, per facility policy, after the medication were discontinued.) 5. During an interview on 04/28/26 at 8:39 A.M., the Staffing Mentor/Educator said she and the Assistant Director of Nursing (ADON) usually destroyed the medications in the medication storage rooms. She tried to check the storage rooms for medications to be destroyed at least once a week. It had been a week or two since she checked the cabinet for medications to be destroyed. She destroyed medications on 04/23/26 with the Administrator. There were no medications left in the cabinet to be destroyed. Discontinued or completed medications had to be destroyed at least once per month. During an interview on 04/29/26 at 5:21 P.M., the ADON said she usually destroyed medications with the Staffing Mentor/Educator. The Administrator destroyed medications with the Staffing Mentor/Educator last week while he/she was on vacation. Staff usually destroyed medications every week. During an interview on 04/30/26 at 2:50 P.M., the Administrator said staff should destroy medications in a timely manner. During an interview on 04/30/26 at 2:50 P.M., the Corporate Director of Nursing (DON) representative said staff should destroy medications at least monthly.

Based on observation, interview, and record review, the facility failed to provide a nourishing and well-balanced diet to meet dietary needs when staff failed to follow the recipe when preparing the lunch entree on 04/27/26 and failed to ensure staff prepared sufficient food to serve all residents the food items on the lunch menu for 04/27/26. The facility census was 116. Review of the Diet Spreadsheet on 4/27/26 for the lunch meal showed the meal was to include ravioli bake (one slice), cauliflower, breadstick, and apple orchard bar. Observation on 4/27/26 between 12:00 P.M. and 12:45 P.M. during the lunch meal service showed Dietary Staff M served ravioli bake, cauliflower, rolls and canned fruit. Observation on 4/27/26 at 12:46 P.M. during the lunch meal service showed the kitchen ran out of the ravioli bake entree and rolls. Staff served three residents on the 500 Hall the entree. Staff served the remaining residents (approximately 15 residents) on the 500 Hall a ham and cheese sandwich instead of the ravioli bake entree and served biscuits instead of rolls. During interviews on 4/27/26 at 12:49 P.M. and 1:15 P.M., Dietary Staff M said the following:-He/She was probably giving the residents a larger portion of the entree than needed;-He/She served the ravioli bake with a 6-ounce serving scoop. The dietary manager selected the scoop he/she was supposed to utilize for the entree. During an interview on 4/27/26 at 12:50 P.M., the Dietary Manager said the cook who prepared the lunch items should have prepared four pans of ravioli instead of three. She instructed the cook to serve the remaining residents on the 500 Hall (those that did not receive the ravioli bake) a ham and cheese sandwich, cauliflower, creamed corn (alternate vegetable option) and a biscuit (as the facility had run out of rolls). During an interview on 4/27/26 at 5:50 P.M., Resident #79 said the facility ran out food a lot and the only alternative available was a cold-cut sandwich. 2. Review of the recipe for ravioli bake showed the ingredients included spaghetti sauce, cheese ravioli, cottage cheese, mozzarella cheese, and parmesan cheese. During an interview on 4/28/26 at 10:00 A.M., the Dietary Manager said Dietary Staff N did not properly prepare the lunch on 4/27/26. Dietary Staff N should have added cottage cheese and mozzarella cheese to the ravioli bake and did not. She did not watch Dietary Staff N prepare the entree. Dietary Staff N was a newer employee, was young and needed more training. Cooks should follow the recipe when making food items. During an interview on 4/28/26 at 10:15 A.M., Dietary Staff N said staff should follow the recipe when preparing food items. He/She thought the ravioli bake already had the cottage cheese and mozzarella cheese included inside the ravioli, so he did not add these ingredients to the entree. 3. During an interview on 5/5/26 at 2:11 P.M., the Consultant Dietitian said the following:-The facility could have run out of a food item for possibly serving too portions that were too large, or they may not have prepared the item properly;-The facility probably should have served something hot in place of the ravioli bake on 4/27/26, but it would have to be prepared quickly since this occurred near the end of the meal service.

Based on observation, interview, and record review, the facility failed to prepare and serve food items to conserve nutritive value, flavor, appearance and temperature. The facility census was 116. Review of the undated facility policy, Food Temperatures, showed the following:-Foods will be served at proper temperature to ensure food safety;-Take the temperature of each pan of product before serving;-Acceptable serving temperatures are: -Cereal, gravy, casseroles, meat, entrees, potatoes, pasta, soup, pureed foods, hot pureed foods, cold vegetables, coffee: >140 degrees but preferably 160-175 degrees; -Hazardous salads and desserts <41 degrees; -Eggs 140-155 degrees;-If temperatures are not at acceptable levels and cannot be corrected in time for meal service, make an appropriate menu substitution and discarded out of temperature range foods. 1. During an interview on 04/26/26 at 11:19 A.M., Resident #6 said the food was not good. The food was fake and rubbery and was very low-quality food. Most of the time, the food had no flavor and was served at room temperature. During an interview on 04/26/26 at 11:26 A.M., Resident #66 said the food was not hot, it was usually room temperature. The facility did not give the residents condiments like ketchup, mustard, or mayo with their meals. During an interview on 04/26/26 at 11:26 A.M., Resident #42 said the food was not good. There is no seasoning. Staff never sent condiments. The food tasted like staff just dumped a can and was barely warmed. Staff served burnt pizza, and the sausage was undercooked. Staff served powdered eggs, and no one liked them. The food was never hot; you are lucky if it was warm. During an interview on 04/26/26 at 11:26 A.M., Resident #55 said the food was always cold. Staff never gave the residents ketchup and mustard. The food was often undercooked or overcooked and mushy. During an interview on 04/26/26 at 11:44 A.M., Resident #15 said a lot of the food was greasy and was not very good. The food did not taste good at all. During an interview on 04/26/26 at 3:04 P.M., Resident #31 said the food was not very good and was often bland. During an interview on 04/26/26 at 3:49 P.M., Resident #107 said the food was not good. Staff boiled everything to the point of mush and it was not good. During an interview on 4/27/26 at 5:50 P.M., Resident #79 said the food was not very good. It rarely was hot, most of the time it was barely warm. During an interview on 4/28/26 at 2:40 P.M., Resident #84 said the food was not great. 2. Record review of the Diet Spreadsheet for lunch on 4/27/26 showed staff were to serve ravioli bake and cauliflower. Observation on 4/27/26 at 12:57 P.M. showed the lunch service ended. Observation on 4/27/26 at 12:58 P.M. showed Dietary Staff M prepared sample test tray. Observation on 4/27/26 at 1:01 P.M. of the sample test tray, showed the following:-Staff did not serve the ravioli bake as the facility ran out of this item during the meal service;-The temperature of the cauliflower was 90.3 degrees Fahrenheit (F). The cauliflower tasted cold;-The temperature of the creamed corn (alternate vegetable) was 109.7 degrees F and tasted cold. 3. Record review of the Diet Spreadsheet for lunch on 4/28/26 showed staff were to serve the following:-Chicken teriyaki;-Broccoli (medley of yellow squash, snow peas, broccoli and carrots was substituted for broccoli). Observation on 4/28/26 at 12:50 P.M. showed the lunch service ended. Observation on 4/28/26 at 12:51 P.M. showed Dietary Staff M prepared the sample test tray. Observation on 4/28/26 at 12:51 P.M. of the sample test tray showed the following:-The temperature of the chicken teriyaki was 108.6 degrees F. The chicken tasted cold;-Vegetable medley of yellow squash, snow peas, broccoli and carrots was 100 degrees F and was cold to taste. During an interview on 4/28/26 at 1:12 P.M., the Dietary Manager said staff should serve hot food items at a temperature of at least 120 degrees F. During an interview on 5/5/26 at 2:11 P.M. the Consultant Dietitian said the following:-Staff should serve hot food items at 120 degrees F;-She was unaware the residents complained of cold food.

Based on observation, interview, and record review, the facility failed to provide food that accommodated residents' allergies, intolerances, and preferences, when staff served fish to one resident (Resident #120), who had an allergy to fish and seafood which resulted in an allergic reaction of a rash and itching skin that required medication. The facility failed to provide food/drink items to one resident (Resident #5), in a review of 30 sampled residents, and one additional resident (Resident #55) per their preference. The facility census was 116. Review of the undated facility policy, Diet Identification Card, showed the following:-A diet identification tray card will be completed for each resident by authorized Dietary personnel to ensure residents receive the proper diet as ordered by the physician;-Include information as appropriate, such as beverage and food preferences and food allergies. 1. Review of Resident #120's face sheet showed the resident was admitted to the facility on [DATE]. The resident had an allergy to fish and seafood. Review of the resident's allergy report, dated 04/17/26, showed the resident had an allergy to fish and seafood. Review of the resident's physician's orders sheet, dated 04/17/26, showed the resident had an allergy to fish and seafood. Review of the resident's baseline care plan, dated 04/17/26, showed the resident had an allergy to fish and seafood. Review of the resident's pink dietary order slip, completed by nursing staff on 4/17/26, showed the resident had an allergy to fish and seafood. Review of the Week at a Glance menu for lunch on 4/17/26 showed the menu included oven fried fish. Review of the resident's medication administration record (MAR), dated 04/17/26, showed staff administered 50 milligrams (mg) of Benadryl (antihistamine) at 11:08 P.M. Review of the resident's nurses' notes, dated 04/17/26 at 11:08 P.M., showed staff administered Benadryl for complaints of itching to the resident's abdomen. The staff documented the resident had a rash. Review of the resident's nurses' notes, dated 04/18/26 at 12:35 A.M., showed the resident said the Benadryl helped with the itching. The areas of rash remained red. During an interview on 04/26/26, at 1:09 P.M., the resident said he/she was allergic to fish. Staff served him/her fish about a week ago. He/She didn't eat the fish on his/her plate, but it contaminated his/her noodles. He/She broke out into hives and had to take Benadryl twice for the hives caused by the fish. During interviews on 4/28/26 at 10:00 A.M., 12:21 P.M., and 1:12 P.M., the Dietary Manager said the following:-Nursing staff completed a pink diet slip when the resident was admitted , and she was not aware the resident had an allergy;-She was on vacation when the resident was admitted to the facility. Dietary staff made out the tray ticket for the resident in her absence;-Dietary staff were not aware the resident was allergic to anything;-Staff served fish for the meal on 4/17/26;-The resident did not like fish;-If the resident had an allergy, it would be listed on the tray ticket. The resident did not have any allergies according to the tray ticket;-Staff should not serve a resident fish if the resident had a fish allergy;-She did not complete a formal tray ticket for the resident until 4/27/26. During an interview on 5/5/26 at 2:11 P.M., the Consultant Dietitian said staff should list the resident's allergies on the resident's tray ticket. 2. During an interview on 04/26/26 at 4:25 P.M., Resident #55 said he/she requested milk with his/her lunch, but staff told him/her he/she couldn't have milk and could only have tea or lemonade. Observation and interview on 04/30/26, at 12:10 P.M. showed the resident sat at the dining room table. Staff served him/her a meal tray. Staff did not serve the resident milk with his/her meal. The resident said he/she requested milk, and the staff told him/her to drink tea or lemonade. During an interview on 04/30/26, at 12:25 P.M., Certified Nurse Assistant (CNA) H said the dietary staff was supposed to put milk on the trays for residents who had orders for milk. There was never milk in the refrigerator on the unit for the residents. Staff would have to go to the kitchen to get milk. The other residents would get upset if staff had to stop passing their meal trays to go to the kitchen to get milk. He/She could get milk for the residents after he/she finished passing trays but by then the resident would probably be done eating. If there was milk on the unit or dietary staff sent milk with the meal trays, it would be possible to give the residents milk when requested. During an interview on 4/28/26 at 12:21 P.M., the Dietary Manager said the following:-Staff prepare all the drinks in the kitchen;-Dietary staff served milk with breakfast; -Residents can ask for milk when they want milk;-There should be cartons of milk in the Station One and Station Two nurses stations;-If she was aware a resident wanted milk, staff could add it to the resident's meal tray card;-She was unaware Resident #55 wanted milk with meals. The resident did not require a physician's order for milk. 3. Review of the spreadsheet menu for the evening meal on 4/27/26 showed staff were to serve bean soup, crackers, ham and cheese sandwiches, carrot and raisin salad, pudding parfait and beverage. Observation on 4/27/26 at 5:53 P.M., showed the following:-Staff served Resident #5 a cheese sandwich with one slice of bread, one heel (end piece) of bread and one slice of cheese;-The resident's meal card had a handwritten note stating, no ham sandwich. The resident was on a regular diet, with no restrictions. During an interview on 4/27/26 at 05:54 P.M., Resident #5 said the following:-He/She would like to have a ham and cheese sandwich that was shown on the menu;-He/She received a cheese and bread sandwich;-He/She liked deli ham. During an interview on 4/28/26 at 12:21 P.M., the Dietary Manager said Resident #5 only liked a specific cut of deli ham and not regular ham. The facility did not have the preferred item available to serve. Staff should prepare a sandwich with two slices of bread, two to four slices of deli meat (depending on thickness), and one to two slices of cheese. Staff should not use the heels of the bread.

Based on record review and interview, the facility failed to ensure compliance with the Federal requirement for nurse aide training when the facility charged nurse aides, employed by the facility, for the cost of the nurse aide training program. The facility census was 116.Review of the Code of Federal Regulation, 42 CFR 483.152 Requirements for approval of a nurse aide training and competency evaluation program, showed the following:(c) Prohibition of charges. (1) No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide training and competency evaluation program may be charged for any portion of the program (including any fees for textbooks or other required course materials).Review of the undated facility policy, Agreement Between (the facility corporation) and Employee Regarding Payment for CNA Courses, showed the following: -This agreement (Agreement) is made and entered into by and between (the facility corporation) (hereinafter referred to as the Employer) and the undersigned employee (hereinafter referred to as the Employee);-1. Course Payment and Employment Commitment: The employer agrees to cover the cost of the Certified Nursing Assistant (CNA) training course for the employee in the amount of $700. In exchange, the employee agrees to commit to employment with the employer for a minimum of 12 months starting from the date of course completion;-2. Repayment Terms: The employee agrees to repay the employer the total sum of $700, prorated over the course of 12 months. This repayment will be deducted from the employee's paycheck on a bi-weekly basis in the amount of $26.92 per pay period. The first deduction will occur in the pay period following the Employee's completion of the CNA course;-3. Prorated Payback Clause: If the employee voluntarily resigns or is terminated for cause before completing 12 months of employment, the Employee agrees to repay the remaining balance of the course cost. The outstanding balance will be calculated by multiplying the number of remaining pay periods by the bi-weekly deduction amount. The employer will withhold any outstanding balance from the Employee's final paycheck;-4. Payment Arrangements: In the event the employee's final paycheck does not fully cover the remaining amount owed, the employee agrees to make payment arrangements with the Employer. The terms of such payment arrangements will be mutually agreed upon but must ensure full repayment within a reasonable period;-5. Acknowledgment: By signing this agreement, the employee acknowledges that they have read, understand, and agree to the terms and conditions herein. This agreement shall be binding upon the parties and their respective heirs, legal representatives, successors, and assigns;-This agreement constitutes the full and complete understanding between the parties regarding the matters addressed herein and may not be altered or amended except in writing signed by both parties. 1. Review of the facility provided agreement, between the facility corporation and NA Z, regarding payment for the CNA course showed NA Z and Human Resources (HR) signed the contract on 2/18/26. During an interview on 04/28/26 at 1:56 P.M., NA Z said the facility paid for his/her CNA course but he/she had to pay it back after he/she finished the course. The facility will take money out of each paycheck until he/she has paid them back for the course. 2. Review of the facility provided agreement, between the facility corporation and NA E, regarding payment for the CNA course showed NA E and HR signed the contract on 01/12/26. During an interview on 04/29/26 at 4:20 P.M., NA E said the facility paid for his/her CNA course when he/she started the course. The facility took money from each of his/her paychecks to pay them back for the course. 3. Review of the facility provided agreement, between the facility corporation and NA X, regarding payment for the CNA course showed NA X and HR signed the contract on 01/15/26. During an interview on 05/08/26 at 8:30 P.M., NA X said the following:-He/She started taking CNA classes a couple of months ago;-He/She was in classes when he/she signed a contract with the facility;-He/She did not remember the specifics of the contract, but the facility paid for his/her CNA course and he/she had to pay them back;-If he/she left employment before six months, the facility would take his/her last paycheck. 4. Review of the facility provided agreement between the facility corporation and NA G, regarding payment for the CNA course showed NA G and HR signed the contract on 10/30/25. 5. Review of the facility provided agreement between the facility corporation and NA S, regarding payment for CNA course showed NA S and HR signed the contract on 04/08/26. 6. During an interview on 04/26/26 at 6:00 P.M., the Human Resources Manager said she was instructed to have the NAs sign the contract to take a portion of money out of each paycheck until the NAs had paid the facility back for the CNA course. She was unaware there was a regulation against requiring the NAs to pay the facility for the CNA courses. During an interview on 04/26/26 at 11:15 A.M., the Administrator said the facility paid for NAs to attend the CNA course. The NA sign a contract stating they will pay a small amount from each paycheck to the facility for the CNA course. If the NA ends employment before 12 months, the employee had to pay the remaining sum back to the facility out of their last check.

Based on observation, interview, and record review, the facility failed to ensure the call system was audible to ensure staff were alerted to the residents' request for assistance. The facility census was 116. Review of the facility policy, Call Lights Accessibility and Timely Response, revised on [DATE], showed the following:-The purpose of this policy is to ensure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response;-Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.);-Ensure the call system alerts staff members directly or goes to a centralized staff work area.-All staff members who see or hear an activated call light are responsible for responding 1. Observations from [DATE] to [DATE] showed the call light monitor and audible signal was located in the locked nursing station for Station One (100, 200 and 300 halls). Plexi glass windows enclosed the nursing station. The lights, located above each resident room door, turned on when the residents in the rooms turned on the call lights. The audible signal from the call light monitor could not be heard from outside the Station One nursing station. The audible signal from the call light monitor could not be heard at the entrance to the 100, 200 and 300 hallways. Observations on [DATE] showed the following:-At 1:50 P.M., the call light above the door to room [ROOM NUMBER] was turned on. No staff were in the hallway. -At 2:01 P.M., the call light for room [ROOM NUMBER] was on. No staff walked to the end of the hall where the room was located between 1:50 P.M. and 2:01 P.M.-At 2:06 P.M., the call light for room [ROOM NUMBER] was on. No staff walked to the end of the hall between 2:01 P.M. and 2:06 P.M.-At 2:09 P.M., the call light for room [ROOM NUMBER] was on. No staff walked to the end of the hall between 2:06 P.M. and 2:09 P.M. The light above the room door was not visible from the front of the hall near the nurses' station. There was no audible sound near the nurses' station to indicate the call light in room [ROOM NUMBER] was turned on; -At 2:17 P.M., NA G walked down the hall but did not answer the call light for room [ROOM NUMBER]. The call light over the door was on, however, there was no audible sound at the nurses' station to indicate the call light was on;-At 2:26 P.M., the call light for room [ROOM NUMBER] was on. No staff walked to the end of the hall between 2:17 P.M. and 2:26 P.M. The light above the room door was not visible from the front of the hall near the nurses' station. There was no audible sound near the nurses' station to indicate the call light in room [ROOM NUMBER] was turned on. During an interview on [DATE] at 11:30 A.M., Certified Nurse Assistant (CNA) CC said he/she could hear the call lights for Station One when in the nursing station, but it was difficult to hear the call lights when he/she was outside the nursing station. During an interview on [DATE] at 1:42 P.M., Licensed Practical Nurse (LPN) F said the following:-He/She could only hear the Station One call lights when he/she was inside the nursing station. He/She could not hear the call lights when in the dining room or hallways;-The only way staff knew if call lights were on in the hallways (100, 200, and 300) was to look at the lights above the residents' doors;-Staff could not see the 300 hallway when they were in the dining room or on the 100 and 200 halls. If staff were not in the nursing station or on the 300 hall, they would not know if a resident turned on a call light on the 300 hall;-Staff could not see the call lights above the doors for the last four rooms on the 200 hall (210, 211, 212, and 213) from the dining room or from the Station One nursing station. Staff had to walk a quarter of the way down the hallway or squat to the ground in order to see those lights due to the wall structure.-If staff could not hear and see the call lights, it could cause delays in staff answering the residents' call lights. During an interview on [DATE], at 2:29 P.M., LPN F said the call lights were not audible unless staff were inside the Station One nursing station. The CNAs would not know a call light was on unless they saw the lights above the door to the resident's room. Observation on [DATE] at 2:29 P.M. showed LPN F opened the Station One nursing station door. The call light monitor was on a screen mounted to the wall. A low beep could be heard from the call light monitor when in the nursing station but was not audible outside of the nurses' station. During an interview on [DATE] at 2:30 P.M., CNA C and Nurse Assistant (NA) G said the call lights were not audible unless they went into the nursing station and they did not go in there often. The only way they knew the call lights were on was if they saw the light above the door. They had to walk down the 200 hall to see the lights above the door for the last four rooms. In order to see the call lights for the 300 hall, they had to walk to that hall to see the lights. The lights on the 300 hall were not visible from the nurses desk. NA G said sometimes residents were upset because staff didn't come quickly to answer their call light but the staff did not know the call light was on. During an interview on [DATE] at 4:15 P.M., NA S said the following:-He/She could not hear the call lights in the hallways, only at the Station One nursing station;-When he/she was on the hall, the only way he/she knew if the call light was turned on was to look at the lights above the residents' doors;-Staff could not see the 300 hall call lights from the 100 or 200 halls, which could delay staff's response to the call lights. During an interview on [DATE], at 3:08 P.M., the Administrator said the call lights used to be very loud and no one had reported they were no longer audible outside the nursing station. She expected the call lights to be audible outside the nursing station so the aides could hear them.

Based on interview and record review, the facility failed to provide protective oversight and complete 15 minute safety checks (procedure for staff to verify the resident's location) as directed for one resident (Resident #1), in a review of seven residents. Resident #1 was a known elopement risk and was on 15 minute face checks for safety when the resident removed the security block from the windowsill (a rubber block screwed into the windowsill preventing the slide window from opening more than five inches) in his/her room, opened the window, removed the screen and climbed through the window to the exterior fenced courtyard. The resident pushed a picnic table next to the building, stood on the picnic table and climbed onto the roof, crossed the roof, and then jumped down into an open area. The resident walked from the back of the building, down the street, five blocks, until he/she was approached by a local police officer. The facility census was 111. On 3/12/26 at 11:15 A.M. the Administrator was notified of the Immediate Jeopardy Past Non-Compliance which occurred on 02/28/26. On 02/28/26, the Administrator identified Resident #1 eloped from the facility through his/her room window to a 12-foot-high fenced in courtyard, climbed onto the roof and jumped down to an open area, and walked down the street five blocks without staff knowledge. Upon discovery, Resident #1 was located and transferred to the hospital by ambulance per the resident's request. The resident returned to the facility on [DATE] at 2:16 A.M. and immediately placed on one-on-one observation for safety. The resident's guardian and physician were notified of the elopement, and the resident was evaluated by psychiatric services. Additional interventions were implemented to ensure the security of the resident's window as well as all windows in the facility. The courtyard picnic table was secured to the concrete patio. Education for all staff was started immediately regarding the resident elopement policy, residents at risk for elopement, intensive monitoring procedures including one-on-one observation and every 15-minute face checks including documentation of the face checks and window security. The deficiency was corrected on 03/01/26. Review of the facility Elopement and Wandering Residents policy, dated 06/12/24, showed the following:-The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk;-Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so;-The facility is equipped with door locks/alarms to help avoid elopements;-Alarms are not a replacement for necessary supervision;-The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment or risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary;-Resident will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the care interdisciplinary care plan team;-The interdisciplinary team will evaluate the unique factors contributing to risk to develop a person-centered care plan;-Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff;-Adequate supervision will be provided to help prevent accidents or elopements;-Charge nurses and unit managers will monitor the implementation of interventions, response to interventions and document accordingly;-The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff;-Following an elopement a nurse will perform a physical assessment, document and report findings to the physician;-A social service designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults;-The resident and family/authorized representative will be included in the plan of care;-Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. Review of the facility Intensive Monitoring policy, dated 04/30/24, showed the following:-The purpose was to ensure a system for residents who required increased monitoring for crisis, behavioral, or psychiatric issues;-Intensive monitoring is defined as periodic checks by a facility staff member; intensive monitoring based on the crisis, behavioral, psychiatric issues. The level of monitoring shall be identified by the specific situation or resident assessment;-Residents who show poor impulse control such elopement ideations, may be placed on intensive monitoring or one-on-one or two-to one (within eyesight of staff) monitoring at the discretion of the administrative staff or supervisor;-The facility's Interdisciplinary Team (IDT) will address the resident's behavioral concerns and ensure interventions are in place to address the resident's needs (psychiatry follow up, counseling, medical needs);-Once the resident has stabilized and/or returned to prior level of function, the facility's IDT will meet to discuss determination of discontinuation of intensive monitoring;-The facility staff will document the intensive monitoring in the resident's electronic medical record. Review of Resident #1's Preadmission Screening and Resident Review (PASRR, a screening tool used to ensure appropriate placement of persons known or suspected of having a mental impairment, serious mental illness and/or intellectual disability/developmental disability) dated 07/24/25, showed the following:-Diagnoses of schizoaffective disorder (chronic mental illness psychoactive substance abuse (harmful or hazardous consumption of substances that alter the brain function, mood, perception or consciousness);-Long family history of mental health issues. hospitalized at [AGE] years old due to suicidal thoughts. Used drugs as a teenager and became addicted. He/She was in and out of different rehabilitation units and left without completing the program. Lived on the streets, was homeless and overdosed on fentanyl (powerful opioid pain medication, illicitly used is a major contributor to fatal overdoses) about two months ago. Reported being physically abused by a parent and sexually abused by someone who drugged the resident;-Needs or continues to need individual, family or group psychotherapy, health behavior assessment and intervention and required ongoing psychiatric care and treatment;-The resident needed support and services. Maintain environment with low stimulation, minimum of visual/auditory distraction and/or sensory supports. Provide for individual personal space. Establish consistent routines, providing a schedule of daily tasks and activities. Provide environmental supports to prevent elopement. Review of the resident's care plan, dated 11/01/25, showed the following:-Diagnoses of schizoaffective disorder (chronic mental illness combining schizophrenia symptoms of hallucinations, seeing and hearing things that are not real, and delusions, a firm belief something is real despite evidence the belief is false, with a major mood disorder such as depression and bi-polar disease, a disease with intense mood swings from depression to mania), psychoactive substance abuse (harmful or hazardous consumption of substances that alter the brain function, mood, perception or consciousness), suicidal ideations (thoughts of killing self), mood disorder, attention-deficit hyperactivity disorder (ADHD, neuro disorder with persistent inattention, hyperactivity and impulsivity that interferes with daily functioning), opioid abuse (abuse of narcotic medication), anxiety disorder, insomnia (inability to sleep) due to other mental disorder, adjustment disorder with depressed mood;-The resident was at risk for elopement due to feelings of anxiety, had a history of elopement from prior, secured facility. Staff should complete an elopement risk assessment on admission, readmission, and quarterly, and complete face checks/intensive monitoring. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 12/09/25, showed the following:-Cognitively intact;-No hallucinations or delusions;-No impaired mobility and required no assistive device;-The resident's wandering placed the resident at significant risk of getting to a potentially dangerous place such as outside of the facility. Review of the resident's elopement risk evaluation, dated 10/28/25, showed staff documented the following:-History of elopement or attempts of leaving the facility without informing staff;-Verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door;-Score of two. Indicating risk of elopement (score of one or higher indicated risk of elopement). Review of the resident's nurses' note, dated 10/28/25 at 11:06 P.M., showed the resident arrived at 9:30 P.M. He/She was hard to redirect, walked independently with a steady gait, was agitated and drug seeking. He/She made several attempts to get out the door. Review of the resident's nurses' note, dated 10/29/25 at 12:07 P.M., showed the Interdisciplinary Team met with the resident. The resident spoke about elopement from previous facilities, and he/she did not feel like he/she needed to be in a facility. Review of the resident's nurses' note, dated 11/1/25 at 7:50 P.M., showed staff documented the resident's guardian called and reported the resident was at a gas station. Code [NAME] initiated. Staff contacted the resident by the resident's personal cell phone, the resident provided his/her exact location. Staff located the resident and safely transported the resident back to the facility. Review of the resident's elopement risk evaluation, dated 11/01/25, showed staff documented the following:-History of elopement while at home;-History of elopement or attempts of leaving the facility without informing staff;-Verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door;-Pattern of goal-directed wandering behavior;-Wandering behavior likely to affect the safety or well-being of self/others;-Wandering behavior likely to affect the privacy of others;-Recently admitted or re-admitted to the facility (within the past 30 days) and had not accepted the situation;-Score of seven. Indicating risk of elopement (five points higher than the elopement risk score from the previous assessment dated [DATE]). Review of the resident's nurses' note, dated 02/26/26 at 11:04 P.M., showed staff documented completing intensive monitoring with every 15-minute face checks. Review of the resident's 15-minute face check documentation (located in the resident's electronic medical record) dated 02/28/26 showed staff documented at 12:00 P.M., 1:10 P.M., 3:32 P.M., 3:35 P.M., and 3:38 P.M. the resident was in the building. Review of the resident's nurses' note, dated 02/28/26, showed staff documented the following:-At 4:58 P.M., a phone call received from off duty staff at 4:40 P.M. Laundry Aide F asked if the resident had a pass because the resident just walked by Laundry Aide F's home. Staff went directly to the resident's room and noted the window was open and the screen was not in place. Code [NAME] was called. Emergency Medical Services (EMS, 911 dispatcher) called the facility asking about the resident. The resident refused to give his/her name to the police officer;-At 5:15 P.M., EMS dispatch informed staff the resident requested an ambulance and cooperated with the police officer;-At 5:45 P.M., hospital emergency department informed the facility staff the resident would return by ambulance and he/she was a very high elopement risk. Review of the Police department report, dated 02/28/26 at 4:20 P.M., showed on 02/28/26 at approximately 4:20 P.M. the police officer observed a person walking near the city park, wearing a bulky winter jacket, pajama pants, and slip-on sandal style shoes which appeared unusual for the weather and location. The police officer drove to the fairgrounds parking area (four city blocks from the facility), parked the vehicle and continued to observe the subject. At 4:40 P.M. a person who identified themselves as a facility employee parked next to the police officer and advised the subject walking was a resident of the facility and not authorized to be out. The employee was on the phone with the facility and verified the resident did not have permission or a pass to leave the facility. The employee said the facility was notified the resident was walking around, but was unsure what actions would be taken or if staff were enroute to locate the resident. The police officer followed the resident southbound on Highway PP (five blocks from the facility) and contacted the resident. The resident said he/she was walking to a local store and did not live at the facility. The police officer stopped at an intersection two blocks further down the street and contacted dispatch to request they contact the facility and determine if a resident was missing. While on scene, the police officer observed the resident walk down the roadway. A few minutes later, the resident turned around and walked back toward the police officer. The resident then admitted he/she lied during the initial contact. The resident identified himself/herself and said he/she left the facility by exiting through a window, climbed onto the roof, sat there for a period of time, jumped off the roof, and left the property. He/She denied any injuries. The resident requested help and said he/she did not feel well and wanted to go to the hospital. Dispatch called EMS. The resident was transported to the emergency department. During an interview on 03/11/26 at 10:00 A.M., the resident said he/she just wanted out of the facility, the place was not right for him/her. The resident bent his/her metal watch band and used the edge of the metal to loosen the screws on the blocks in the windowsill, broke the block out, slid the window open, pushed the screen out and went out the window. It was about a four-foot drop to the ground in a fenced in area. It took about an hour to get the block out of the windowsill and the window open. The resident closed the curtain when staff came in the room to check on him/her. Staff did not notice he/she was trying to open the window. Staff did not always complete 15-minute checks. He/She pushed a picnic table near the building, stood on the picnic table where he/she could reach the guttering and pulled himself/herself up on the roof. He/She walked to the end of the roof line and jumped down to the ground in an open area, walked down the street past the school and park area. A police officer came and asked if the resident was from the facility. At first he/she said no then said yes, he/she was from the facility. The resident knew the police and the staff would come to find him/her. Observation on 03/11/26 at 10:30 A.M. showed the following:-The resident's room window was large (approximately six feet wide by four feet high) with three sections. The large window in the center did not open. The smaller windows on each end slide open towards the center window. Each side window was approximately one and one-half feet wide with screens. Directly out the window was a fenced in courtyard area with a picnic table and chairs. The courtyard was surrounded by a 12-foot-high fence. The roof extended beyond the fenced in courtyard and accessed open space to the back of the building and the street;-The resident walked down the neighborhood street past the high school, city park area to an intersection four blocks from the facility. A parking lot at the fairgrounds was on the corner, the location the police officer observed the resident. The resident crossed a black top, two lane highway and walked another block down a black top, two lane highway leading to another neighborhood. He/She walked two blocks down the neighborhood street to the location the police officer approached the resident. The police officer called an ambulance and transported the resident to the hospital. During an interview on 03/11/26 at 11:00 A.M., the Maintenance Director said the resident ripped the rubber block out of the windowsill, slid the window open, removed the screen and exited the building to the fenced in courtyard. The resident moved the picnic table to the side of the building, stood on the picnic table, accessed the roof, jumped off the roof and walked down the street. The courtyard fence was 12 feet tall. During an interview on 03/11/26 at 11:20 A.M., Nurse Assistant (NA) A said on 02/28/26 the resident was on 15-minute checks due to a previous elopement and risk of elopement. Staff should lay eyes on the resident every 15 minutes and document in the electronic medical record the 15-minute check was completed. During an interview on 03/12/26 at 9:35 A.M., NA C said on 02/28/26 the resident was spiraling, he/she took the resident one time that day to a department head for help getting the resident to calm down. Staff spoke to the resident after lunch and a couple of hours later the resident eloped. Earlier that day the resident tried to open a door and said he/she would run away. On 02/28/26 the resident was on 15-minute checks and staff needed to be monitoring the resident's location and complete the face checks timely and do not miss completing a check. During an interview on 03/12/26 at 12:15 P.M., Certified Nurse Assistant (CNA) E said he/she worked 02/28/26 on the resident's hall and was responsible for completing the resident's 15 minute face checks in addition to other staff working the hall. The resident was irritated, staff knew he/she was irritated before the resident eloped. CNA E was getting another resident out of bed and heard Resident #1 was gone. CNA E completed face checks by opening the resident's door and seeing if the resident was in the room and documented the face checks when he/she had time; 02/28/26 was a busy day with other residents. He/She was behind on completing face checks that day. During an interview on 03/12/26 at 1:00 P.M., Laundry Aide F said on 02/28/26 he/she was driving home and noticed the resident on the street. It was in the afternoon, but he/she was unsure of the exact time. The resident wore pajamas and a coat. He/She called the facility, and staff were not aware the resident had eloped. He/She approached the police officer and told the police officer the resident was from the facility and was not supposed to be outside the facility grounds. During interviews on 03/11/26 at 8:40 A.M. and 12:30 P.M the Administrator said the following:-The resident had a history of elopement. On 02/28/26 the resident unscrewed and broke the window block, slid the window open, pushed the window screen out and went out the window into a fenced area. The resident stood on a picnic table and climbed on the roof, jumped off the roof outside of the fenced area and walked down the street. A police officer found the resident and an off-duty staff member Laundry Aide F saw the resident on the street near Laundry Aide F's home. Laundry Aide F notified the facility the resident was on the street and the police notified the facility. The staff were not aware the resident had eloped;-On 02/28/26 the resident was on 15-minute face checks, the point of care charting in the resident's medical record triggered every 15-minute face checks. Staff should go lay eyes on the resident and document the face check was completed every 15 minutes;-Staff were aware of the resident's elopement risk since admission. The resident had eloped from previous facilities and eloped a few days after admission to the facility. The resident had the ability to figure out how to get out of the facility. He/She was not aware the resident used his/her metal watch band to remove the window block;-The administrator expected staff to complete every 15-minute face checks as directed and document the face checks in point of care charting (electronic medical record). Staff should have observed what the resident was doing when face checks were completed. Staff should not just open the door and ask if the resident was in the room. Staff was aware the resident could manipulate the windows. MO# 2799195

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #1), in a review of seven sampled residents, with diagnoses of mental illness and a history of trauma, received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. The medical record showed on 02/10/26 at 5:48 P.M the resident's guardian/parent said the resident had voiced self-harm ideations. Two days later, on 02/12/26, the resident repeatedly asked for his/her television to watch Animal Planet, a known coping mechanism. Staff failed to provide additional interventions or a television to watch while supervising the resident one-on-one. As a result of not implementing the interventions as care planned, the resident became agitated and broke out a window (inside pane of a double pane glass window) in his/her room, picked up a shard of glass and cut his/her forearm from elbow to wrist. The resident was transported by ambulance to the psychiatric hospital for medical and psychiatric treatment. The resident returned to the facility on [DATE]. On 02/21/26, the resident picked up glass shards that remained in the windowsill from 02/12/26, cut his/her forearm, was transported by ambulance to the emergency room for treatment of the lacerations and returned to the facility. No additional interventions were implemented and on 03/04/26 the resident again found a shard of glass in his/her room that remained from 02/12/26, cut the same forearm and required a bandage for bleeding. The facility census was 111. Review of the facility policy, Behavioral Health Services, dated 10/31/24, showed the following:-It is the policy of the facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning;-Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty and trauma or post-traumatic stress disorders;-The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety; -Conditions that are frequently seen in nursing home resident and may require the facility to provide specialized services and supports based upon residents' individual needs, include, but are not limited to depression, anxiety, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves that can cause hallucinations, delusions and disorganized thinking including paranoia), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs);-The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety;-Staff will monitor the resident closely for expressions or indications of distress, evaluate whether the resident's distress was attributable to their clinical condition and that the change in behavior was unavoidable, utilize Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff) and care area assessments, assess and develop a person-centered care plan for concerns identified, share concerns with the interdisciplinary team (IDT) to determine underlying causes of mood and behavior changes, including differential diagnoses, accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record, ensure appropriate follow up assessments, discuss potential modifications to the care plan, and evaluate the resident and care plan routinely to ensure the approaches are meeting the needs of the resident;-The care plan shall have interventions that are person-centered, evidence based, culturally competent, trauma-informed, and in accordance with professional standards of practice, provide meaningful activities which promote engagement and positive, meaningful relationships, and meet the needs of the residents. Review of the facility policy, Behavioral Emergency, dated 09/23/25, showed the following:-The purpose was to provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure the resident is not being coerced, punished or disciplined for staff convenience;-Care will be directed by the resident's plan of care and will help to respond to difficult behaviors in the safest and most effective way possible;-Proactive management for the resident is the best plan. All staff should recognize when the resident becomes or can become a danger to themselves or someone else. De-escalation techniques should be utilized as the first resort;-Should the resident exhibit extreme behaviors such as suicidal, homicidal, self-mutilation which did not respond to the non-violent crisis intervention, the licensed nurse and/or nursing administration will assess the resident ensuring the safety of the resident and others. Monitoring of the resident will be initiated, if appropriate. The licensed nurse will document the behavioral emergency in the medical record and notify the administration, physician and/or psychiatrist and responsible party;-The IDT will ensure the care plan is updated if appropriate;-At regular intervals, the company will review incidents to obtain root cause analysis which will facilitate improvements of care management and further prevention of incidents. Review of the facility Intensive Monitoring policy, dated 04/30/24, showed the following:-The purpose was to ensure a system for residents who required increased monitoring for crisis, behavioral, or psychiatric issues;-Intensive monitoring is defined as periodic checks by a facility staff member;-One-on-one monitoring is defined as a designated staff member assigned and within eyesight of the resident;-Residents may require more intensive monitoring based on the crisis, behavioral and psychiatric issues. The level of monitoring shall be identified by the specific situation or resident assessment;-Residents who show poor impulse control such as verbal or physical aggression, elopement ideations, suicidal/homicidal ideations, and decompensation mentally or crisis may be placed on intensive monitoring or one-on-one or two-to one (within eyesight of staff) monitoring at the discretion of the administrative staff or supervisor;-Residents who require intensive monitoring of one-on-one will have an assigned staff member within eyesight until the resident is stabilized or returned to prior level of function. The assigned staff member is educated on the reasoning for the intensive monitoring, including triggers and interventions for that specific resident, the staff member will interact with the resident throughout to ensure the resident receives therapeutic interventions;-The facility's IDT will address the resident's behavioral concerns and ensure interventions are in place to address the resident's needs (psychiatry follow up, counseling, medical needs);-Once the resident has stabilized and/or returned to prior level of function, the facility's IDT will meet to discuss determination of discontinuation of intensive monitoring;-The facility staff will document the intensive monitoring in the resident's electronic medical record. 1. Review of Resident #1's Preadmission Screening and Resident Review (PASRR, a screening tool used to ensure appropriate placement of persons known or suspected of having a mental impairment, serious mental illness and/or intellectual disability/developmental disability) dated 07/24/25, showed the following:-Diagnoses of schizoaffective disorder (chronic mental illness psychoactive substance abuse (harmful or hazardous consumption of substances that alter the brain function, mood, perception or consciousness);-Long family history of mental health issues. Around the age of 12 to[AGE] years old, he/she was bullied at school to the point the other teenager was arrested for the bullying. His/Her sibling committed suicide when the resident was in high school and then the resident stopped going to school. hospitalized at [AGE] years old due to suicidal thoughts. Used drugs as a teenager and became addicted. He/She was in and out of different rehabilitation units and left without completing the program. Lived on the streets, was homeless and overdosed on fentanyl (powerful opioid pain medication, illicitly used is a major contributor to fatal overdoses) about two months ago. Reported being physically abused by a parent and sexually abused by someone who drugged the resident;-Needs or continues to need individual, family or group psychotherapy, health behavior assessment and intervention and required ongoing psychiatric care and treatment;-The resident needed support and services. Maintain environment with low stimulation, minimum of visual/auditory distraction and/or sensory supports. Provide for individual personal space. Establish consistent routines, providing a schedule of daily tasks and activities. Review of the resident's physician order sheet (POS) dated 10/28/25 showed the following:-admission date 10/28/25;-Psychiatric evaluation and treatment as needed;-Buprenorphine (medication used to treat opioid use disorder and manage chronic pain by reducing cravings and withdrawal symptoms) 2 milligram (mg) administer one tablet under the tongue at bedtime;-Bupropion (antidepressant medication used to treat major depressive disorder) 300 mg daily;-Clonazepam (antianxiety medication) 1 mg three times daily for anxiety;-Clonidine (medication used to treat high blood pressure, ADHD and sometimes substance withdrawal) 0.5 mg, administer one-half tablet three times daily;-Diphenhydramine (antihistamine medication used to treat allergies, insomnia, motion sickness) 25 mg every eight hours as needed for itching;-Doxepin (antidepressant medication used to treat insomnia, depression and anxiety) 25 mg two capsules at bedtime;-Hydroxyzine (antianxiety medication also used for tension, allergic reactions and pre-surgical sedation) 50 mg every eight hours as needed for anxiety;-Melatonin (over the counter sleep aid medication) 5 mg, administer two at bedtime;-Gabapentin (medication used for neurological pain and also used for anxiety) 600 mg three times daily;-Olanzapine (antipsychotic medication used to treat schizophrenias and bipolar disorder) 10 mg at bedtime. Review of the resident's comprehensive Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 12/09/25, showed the following:-Cognitively intact;-No hallucinations or delusions;-No impaired mobility and required no assistive device;-Independent in Activities of Daily Living (ADLs). Review of the resident's care plan, updated 12/19/25, showed the following:-Diagnoses of suicidal ideations, mood disorder, attention-deficit hyperactivity disorder (ADHD, neuro disorder with persistent inattention, hyperactivity and impulsivity that interferes with daily functioning), opioid abuse (abuse of narcotic medication), anxiety disorder, insomnia (inability to sleep) due to other mental disorder, adjustment disorder with depressed mood;-The resident was at risk for nervousness, pacing on the unit and restlessness related to anxiety. Staff should closely watch for signs of anxiety and act before the resident lost control. Do not argue or tell the resident they are wrong when he/she was upset, do not get into a power struggle with the resident, offer activities to keep the resident from getting bored and provide opportunity to release energy in a healthy way, offer medication before a behavioral outburst occurred, offer non-invasive coping mechanisms first to try to reduce anxiety level. Assist with finding the cause of the anxiety;-The resident had a diagnosis of ADHD. Staff should establish consistent routines;-History of post-traumatic stress disorder (PTSD). PTSD affected the resident's symptoms and may flare up without any known trigger. PTSD was attributed to his/her sibling's suicide and loss of a child. Staff should assess anxiety level, determine severity of condition and course of treatment or therapy needs, assess for suicidal or homicidal ideations to ensure safety of the resident and others, encourage resident o express emotions in a safe environment. Allow resident the freedom to acknowledge feelings and release any repressed emotions. A safe environment should be free from actual or perceived judgement and physical or perceived danger. Encourage the resident to verbally identify current ineffective coping techniques, provide calming and reassuring environment and provide counseling when needed;-The resident's history included a long family history of mental health issues, being significantly bullied at school, sibling committed suicide when the resident was in high school and led to the resident quitting school. At [AGE] years old the resident lost two friends in a car accident. Became homeless but still saw his/her child weekly until the child passed away;-The resident had a coping psychotic disorder. Staff should determine the resident's coping methods, encourage participation in self-calming behaviors such as breathing exercise, meditation or guided imagery, encourage times of rest and relaxation between care activities, evaluate verbal expressions of fear, provide reassurance and when possible, provide continuity of care amongst care providers;-The resident was independent with ADLs. Staff should provide protective oversight and assist as needed. Review of the resident's suicide severity risk assessment, dated 02/09/26, showed the resident had not wished they were dead or could go to sleep and not wake up in the past month, had not thought about killing self in the past month, had not previously done anything or prepared to do anything to end his/her life. The resident scored zero and was considered low risk on the suicide severity rating scale. Review of the resident's nurses' notes showed staff documented the following:-On 02/10/26 at 5:48 P.M., call received from guardian/parent, reported the resident voiced self-harm ideations. The resident came to the dining room while staff spoke with the guardian. Resident had flat affect. Assessed the resident for any marks or self-harm, no red marks noted on arms, neck or torso. Placed resident one-on-one staff supervision. Administrative staff, physician and psychiatric Nurse Practitioner (NP) notified;-On 02/10/26 at 6:13 P.M., resident was one-on-one with staff for safety. Staff needed to search the resident's room and remove any harmful objects for safety. Review of the resident's nurses' notes showed the following:-On 02/12/26 at 4:00 P.M., phone call received from 911 dispatcher. The resident called 911 (Emergency Medical Services - EMS) from the bathroom on his/her personal cell phone. The one-on-one staff member sat outside the resident's bathroom door. The resident refused to leave the bathroom. The Assistant Director of Nursing (ADON) arrived, and the resident came out of the bathroom. The ADON spoke with the 911 dispatcher and the phone call ended. Another resident had an emergency on the other side of the facility. The ADON and charge nurse responded to the other emergency. The one-on-one staff member remained with the resident. The resident became agitated and knocked over linen carts and threw things. The resident went to his/her room and tried to break the window to get out. Staff calmed the resident; the resident called his/her parent/guardian. The resident was safe and continued with one-on one staff monitoring;-On 02/12/26 at 5:00 P.M., the resident broke the glass window in his/her room. The resident was not speaking, sat on the bed surrounded by glass. Resident escorted to the dining room, three scratches on the inside of the forearm. Pressure held to stop bleeding, wounds cleansed and covered with a wound bandage. Small cut on the middle finger of the right hand. The resident's physician and guardian were notified. Review of the resident's psychosocial post-incident impact note, dated 02/12/26 at 5:45 P.M., showed the resident was the aggressor in an incident. He/She did not answer when asked if he/she felt safe or felt the need to talk with someone. The resident did not answer when asked if he/she could identify a staff member the resident felt safe with to share thoughts and feelings. The resident said he/she wanted to go to the hospital. Review of the resident's nurses' notes showed staff documented the following:-On 02/12/26 at 5:56 P.M., EMS transported the resident to the emergency department for evaluation;-On 02/12/26 at 6:57 P.M., report called to the emergency department. Reported recent behavior of breaking the window, laceration to the left inner forearm, increased anxiety and elopement risk. Review of the resident's care plan, updated 02/12/26, showed the resident broke out the window in his/her room. Staff should provide intensive monitoring, education on use of coping skills and review of coping skills. Review of the resident's nurses' notes dated 02/18/26 at 11:00 P.M. showed staff documented the resident returned from the hospital to the facility at 5:15 P.M. Resident placed on every 15-minute checks for safety. Pleasant mood, no complaints of suicidal ideations. Attended smoke break and ate a snack. Review of the resident's hospital discharge orders dated 02/18/26 showed the following new medication and treatment orders:-hospitalized for suicidal ideations and self inflicted superficial lacerations of the left forearm;-Buprenorphine-Naloxone (Suboxone) ( a combination drug used to treat opioid use disorder and treat overdose) 8-2 mg one film under the tongue (a film containing the medication absorbed when placed under the tongue) every morning;-Bupropion increase to 300 mg daily;-Discontinue clonazepam, gabapentin and buprenorphine;-The resident's medications had been reviewed and/or adjusted. The resident was no longer a danger to self or others;-Follow up with facility providers. Review of the resident's POS dated 02/18/26 showed the following:-Psychiatric evaluation and treatment as needed;-Buprenorphine-Naloxone 8-2 mg one film under the tongue every morning;-Bupropion 300 mg daily;-Clonidine 0.1 mg, administer one-half tablet three times daily;-Diphenhydramine (antihistamine medication used to treat allergies, insomnia, motion sickness) 25 mg every eight hours as needed for itching;-Melatonin (over the counter sleep aid medication) 5 mg, administer two at bedtime;-Olanzapine (antipsychotic medication used to treat schizophrenias and bipolar disorder) 10 mg at bedtime. Review of the resident's suicide severity risk assessment, dated 02/19/26, showed the resident had wished they were dead or could go to sleep and not wake up in the past month, had thoughts about killing self in the past month and thought about how he/she might kill self with some intention of acting on these thoughts, started to work out details of how to kill themselves with no intention to carry out the plan. The resident had previously done something or prepared to do something to end his/her life in the past month. The resident scored 36 and was considered high risk on the suicide severity rating scale. The care plan was updated. Review of the resident's care plan, updated 02/19/26, showed the following:-The resident's suicide risk assessment indicated a high risk for suicide. Staff should keep the resident safe in a protected environment, provide proper tools and coping skills to aide through a crisis to reduce suicidal ideation by administering medications as ordered, relocate to soothing environment, remove items from the room that could be used in the resident's suicide plan and provide suicide/crisis hotline and resources;-The resident had a behavior management problem. Staff should ensure the safety of the resident and others, establish boundaries and limits with the resident, monitor cognitive, emotional and environmental factors that contributed to a behavior, provide emotional support regarding new onset delusions and repetitive behavior, utilize diversion techniques as needed and provide protective oversight. Staff should initiate visual supervision during acute episodes. Review of the resident's nurses notes showed staff documented the following:-On 02/21/26 at 4:54 P.M., the resident approached the charge nurse and said he/she needed attention. Blood leaked moderately from several slash wounds on the resident's forearm. The resident said he/she did it again, clarifying the resident cut his/her arm while alone in his/her room. Several long slash marks noted from the elbow to the wrist some with depth up to two millimeters. Wounds cleansed and bandages applied with pressure to stop bleeding. The resident expressed his/her feelings of sadness and hopelessness. The resident was embarrassed and tried to hide the wounds from the staff. Allowed the resident to express his/her emotions and pointed out several peers and staff members to build a friendship with or talk to. Staff checked the resident's room for objects that could cause harm. The physician and guardian were notified. Physician orders received for transfer to the emergency department for treatment. The guardian reported the resident was increasingly hostile toward him/her making frequent statement such as I hope you die, you stupid whore and the resident felt as though he/she was losing his/her mind;-On 02/22/26 at 2:00 A.M., the resident returned to the facility. Resident one-on-one staff observation. Dressing to left forearm. The resident said he/she planned to break out the window and get out of the facility tomorrow or sooner;-On 02/22/26 at 2:22 A.M., the resident was angry about being one-on-one with staff. The resident tried to pull the privacy curtain and close the door to obscure the view of the resident and window leaving him/her unsafe and unattended. Re-educated the resident of need to be in arm's length and full view for safety/supervision related to his/her suicidal ideations and self-harm attempts;-On 02/22/26 at 1:54 P.M., the resident remained one-on-one for safety. Staff checked the resident's room for safety. The resident initiated conversation with the charge nurse about the incident, saying he/she felt better than the previous day but was still depressed;-On 02/22/26 at 2:28 P.M., the resident approached the charge nurse and asked for something for anxiety. The resident had a nervous look on his/her face, turned away slightly toward the wall when speaking and was running fingers through his/her hair. When asked what coping skills the resident used, the resident said he/she sat in his/her room with one-on-one staff member and talked with other residents. The charge nurse called the psychiatric NP and received as needed order for Haldol (antipsychotic medication used to treat schizophrenia and behavioral problems). Review of the resident's physician order sheet (POS), dated 02/22/26, showed Haldol 5 milligrams every 12 hours as needed for anxiety/agitation, 14 day duration. Review of the resident's care plan, updated 02/23/26, showed the following:-The resident was at risk for self-directed violence related to history of self-harm, impaired coping skills or underlying psychiatric condition. Staff should assess suicidal/self-harm thoughts intent, plan and means. Collaborate with resident to develop a written safety plan, encourage adherence to prescribed medications and encourage resident to identify triggers and early warning signs of self-harm urges. Engage family support and safety planning. Teach and practice alternative coping skills (deep breathing, mindfulness, journaling, calling a friend, sensory grounding);-At risk for self-directed violence related to history of self-harm, impaired coping skills or underlying psychiatric condition. Staff should assess suicidal/self-harm thoughts, intent, plan and means. Collaborate with the resident to develop a written safety plan (list of coping strategies, crisis contacts, safe spaces), encourage the resident to identify triggers and early warning signs of self-harm urges, express feelings, engage family/support system in care and safety planning, teach and practice alternative coping skills (deep breathing, mindfulness, journaling, calling a friend, sensory grounding). Review of the resident's record showed no evidence staff collaborated with the resident and developed a written safety plan as directed in the plan of care, dated 02/23/26. Review of the resident's nurses notes dated 03/04/26 at 5:45 P.M., showed during a 15-minute face check staff noted the resident stood behind his/her room door. The resident said he/she needed help and held out his/her left arm. Minimal blood was noted on the inner forearm with five superficial cuts. Area cleansed, assessed, and bandaged. The resident denied pain. The resident remained in line of site staff supervision. The resident's physician, psychiatric NP, guardian and administrator were notified. Review of the resident's psychiatric NP note, dated 03/04/26, showed the following:-The resident reported experiencing high anxiety recently and said he/she felt frustrated with being in the facility. The resident reported he/she felt many aspects of his/her life were currently outside of the resident's control. Reported significant emotional stress related to the death of his/her child in September 2025, which continued to impact him/her emotionally. The resident denied depressive symptoms and said anxiety was his/her primary concern;-The resident continued to experience emotional distress related to the loss of his/her child. Encourage the resident to discuss feelings related to grief with staff or counseling services as needed. Supportive conversations and structured activities may help reduce rumination and emotional distress. During an interview on 03/11/26 at 1:20 P.M., Dietary Aide B said on 02/12/26 he/she was assigned to provide one-on-one observation of the resident all day. This was the first day Dietary Aide B had provided one-on-one observation of a resident. The resident was on suicide watch because he/she tried to strangle himself/herself with a cord the day before. Staff took all the resident's things that had a cord out of his/her room. The resident wanted his/her television to watch Animal Planet and said over and over he/she just wanted his/her television. Dietary Aide B was supposed to keep the resident from hurting himself/herself or others. The resident asked to see the Environmental Services Supervisor (ESS) several times during the day. The resident thought the ESS could get the resident's television back into his/her room. During the day the resident called and told his/her guardian he/she did not want to be in the facility and wanted out. The resident also called 911 while in the bathroom. Dietary Aide B was not sure what the resident told 911 dispatch. After the resident learned ESS was unavailable and not in the facility, Dietary Aide B could not help the resident. The resident got very agitated, turned over the linen carts in the hallway, threw things in the hallway and broke the window in his/her room out. Glass went everywhere. The resident hit the window with his/her fist. The resident picked up the glass and started cutting himself/herself with a shard of glass. The cuts went straight down the resident's left forearm from the elbow to the wrist. The resident was bleeding and was sent to the emergency room by ambulance. The resident just wanted his/her television to watch Animal Planet, there was nothing in the resident's room for the resident to do that he/she liked. During an interview on 03/11/26 at 2:15 P.M., the ESS said on 02/10/26 staff removed personal items from the resident's room because the resident threatened to strangle himself/herself. Anything with a cord including the resident's television, gaming system, power cords, shoes with laces, sweatshirts with cords were removed and stored in the facility for return later. The resident's personal items were returned partially over time, not all at once, after the resident returned from the hospital. He was not sure when the resident got his/her television back. During an interview on 03/11/26 at 3:30 P.M., the Social Services Designee (SSD) said the following:-On 02/10/26 the resident was suicidal and threatened to strangle himself/herself. Items with cords were removed on 02/10/26, including the power cords, shoelaces and sweatshirts with cords. The resident did not have any of those items in his/her room. The SSD was not aware on 02/12/26 the resident asked for his/her television and was not aware the resident was seeking the ESS to get his/her television back. The resident was on one-on-one observation by staff at all times and there was no reason to keep the resident's television and personal items. There was no risk of suicide while the resident was on one-on-one staff observation. The SSD was not aware the resident became more upset when he/she learned the ESS was not available on 02/12/26, could not get his/her television before the resident broke out the window and cut himself/herself;-The resident got shards of glass from the windowsill after returning from the hospital and cut himself/herself again on 02/21/26. Staff did not thoroughly clean the resident's room and remove all the glass shards prior to the resident returning from the hospital;-On 03/04/26 the resident cut himself/herself again with a shard of glass. The SSD thought the resident hid some glass shards in the room. During an interview on 03/12/26 at 9:35 A.M., Nurse Assistant (NA) C said staff knew the resident's coping mechanisms included watching calming shows on television and writing in notebooks. The resident liked his/her personal things and gaming station. Not having all his/her personal things agitated the resident. The resident should have had his/her television and personal items if staff provided one-on-one observation for safety. On 03/05/26 (one day after cutting himself/herself with glass), the resident showed NA C a metal band in his/her room. NA C and other staff swept the room and found a shard of glass in the curtain. During an interview on 03/12/26 at 12:15 P.M., Certified Nurse Assistant (CNA) E said if the resident was irritated or anxious staff talked with the resident, tried to calm the resident. The resident liked television and watched animal shows, education videos on television, and liked gaming. During an interview on 03/12/26 at 10:30 A.M., the resident said he/she broke the window because he/she was upset with staff and his/her guardian. He/She was suicidal, staff took all his/her coping mechanisms away. He/She wanted to watch animal shows on television and a meditation show on television. He/She liked gaming, music, and television shows. Staff took away his/her sneakers with laces and hoodies with strings. He/She was not sure how long his/her items were gone. The resident had nothing to do, was on one-on-one staff observation and he/she did not like people too close or people who talked too much. That made him/her anxious. The resident was upset the day he/she broke out the window. He/She knocked over the linen cart in the hallway and broke the window with his/her metal cup, grabbed a shard of glass and cut his/her left forearm. He/She always cut his/her left forearm to protect a tattoo on his/her right forearm. He/She wanted to get to the hospital for suicidal thoughts and staff would not send him/her. His/her guardian made the resident mad, so he/she broke out the glass, cut himself/herself and staff then sent the resident to the hospital for one week. At the hospital, his/her medications were changed, he/she was not sure he/she liked the new medication schedule. When the resident returned to the facility, he/she dug around in the windowsill and found glass. He/She wanted to [NAME] against his/her guardian and cut himself/herself again. The resident found glass under his/her bed and cut himself/herself again the third time. The resid[TRUN

Based on interview and record review, the facility failed to protect one resident (Resident #2), in a review of 14 sampled residents, from abuse. Resident #1, who had a diagnosis of intermittent explosive disorder (a mental health condition marked by frequent impulsive anger outbursts or aggression) and had a history of assault, approached Resident #2 and forcefully slammed Resident #2's head against the vending machine and struck Resident #2 multiple times in the face with a closed fist. Resident #2's sustained lacerations to the right eyebrow and upper lip that required sutures. The facility census was 113. Review of the facility's Abuse and Neglect Policy, last reviewed on 06/12/24, showed the following:-Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which included certain resident to resident altercations;-Physical abuse was purposefully beating, striking, wounding, or injuring any resident or any manner. Physical abuse included but was not limited to hitting, slapping, punching, biting, and kicking;-The facility would identify and correct by providing interventions in which abuse was more likely to occur. This would include assessment of the physical environment which might make abuse more likely to occur such as a secluded area, the deployment of staff on each shift in sufficient numbers to meet the resident's needs and that the staff were knowledgeable of resident care needs;-Prevention also included assessment, care planning, and monitoring of residents with needs or behaviors which might lead to conflict. The facility would identify events, patterns, and trends that might constitute abuse and investigate thoroughly. 1. Review of Resident #1's Preadmission Screening and Resident Review (PASRR), a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability who apply or reside in a nursing facility to ensure proper placement, dated 06/04/25, showed the following:-Diagnoses included schizophrenia (a mental disorder characterized variously by hallucinations, delusions, disorganized thinking or behavior), major depressive disorder (a mood disorder that causes persistently low or depressed mood), and stimulant dependence;-He/She had a history of erratic and aggressive behaviors, impulse control issues, anger, labile mood, limited insight, history of hallucinations, and history of assaultive behaviors;-Behavioral symptoms included withdrawn/depressed, suspicious/paranoid, hallucination, delusions, abnormal thought process, and aggressiveness;-He/She had history of assault charges that required jail time;-He/She required 24-hour protective oversight due to severity of behaviors or mental illness symptoms. He/She could not be left without supervision at any time;-Provisions of a structured environment he/she required included an environment with low stimulation, minimum of visual/auditory distractions and/or sensory supports. Assess and plan for the level of supervision required to prevent harm to self or others. Provide individual personal space, and establish consistent routines, providing a schedule of daily tasks/activities, etc. Review of the resident's face sheet showed the following:-He/She was admitted to the facility on [DATE];-He/She had a guardian;-His/Her diagnoses included schizophrenia, bipolar disorder (is a chronic mood disorder that causes intense shifts in mood, energy levels and behavior), and intermittent explosive disorder. Review of the resident's care plan, dated 6/30/25 and last updated 8/13/25, showed the following:-The resident was at risk for the following signs and symptoms related to his/her diagnosis of schizophrenia: aggression, cannot make own decisions, delusions (fixed false beliefs that cannot be reasoned with), and irritability;-The resident had a behavior problem related to intermittent explosive disorder. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 10/01/25, showed the following: -His/Her cognition was mildly impaired;-He/She exhibited physical, verbal, and other behaviors one to three days out of the previous seven-day look back period. Review of the resident's progress notes, dated 11/10/25 at 8:55 A.M., showed at approximately 8:30 A.M., peers (Resident #2 and Resident #3) were in the vending room purchasing a soda when Resident #1 entered the room. Without provocation, Resident #1 forcefully slammed peer's (Resident 2's) head against the vending machine. Peer (Resident #2) fell to the floor at which point Resident #1 struck him/her (Resident #2) multiple times in the face with a closed fist. Review of the facility's investigation, dated 11/10/25, showed the following:-The resident attacked Resident #2 unprovoked on the secure unit. The resident was noted to have struck Resident #2's head against the vending machine then struck Resident #2 while he/she was on the ground several times in the face with a closed fist. Resident #2 sustained lacerations to the right side of his/her face on the eyebrow and right lower lip;-Law enforcement was notified, and the resident was taken into custody;-Injuries were obtained as the result of abuse. During an interview on 11/17/25 at 11:48 A.M., Resident #2 said he/she was in the vending room when Resident #1 attacked him/her from behind. As he/she pushed the button on the vending machine, Resident #1 clobbered him/her while slamming him/her into the soda machine. He/She fell to the ground, and Resident #1 began punching him/her. He/She sustained a laceration of the right eyebrow which required three sutures and a laceration of the right upper lip that required one suture. Review of Resident #2's progress note, dated 11/10/25 at 8:50 A.M., showed the following:-The resident had a 1.5 by 0.5 centimeter (cm) laceration located on his/her right eyebrow;-The resident had a 1 cm by 0.5 cm laceration on his/her right lip. During an interview on 11/17/25 at 11:30 A.M., Resident #3 said he/she was getting a soda and talking to Resident #2 in the snack room. Suddenly, Resident #1 came into the snack room in a full force run and started hitting Resident #2. Review of Resident #13's written statement, provided by the facility, dated 11/10/25, showed he/she was talking to Resident #1. Resident #1 then went to the vending room and started hitting Resident #2. Resident #1 pushed Resident #2 into the snack machine and then to the floor. Review of Certified Nurse Assistant (CNA) F's written statement, provided by the facility, dated 11/10/25, showed he/she was in the nurse's station when he/she heard screaming from the dining room. He/She found Resident #2 on the floor in the vending room bleeding, and Resident #1 walked to the back of the dining room. Residents said Resident #1 beat up Resident #2. During an interview on 11/18/25 at 11:15 A.M., the resident's guardian said prior to admission, he/she spoke to the facility's Director of Nursing (DON) and explained that the resident had intermittent explosive disorder and wanted to make sure they would be able to meet the resident's needs. The resident had a history of assaulting residents at previous facilities. During an interview on 12/3/25 at 1:30 P.M., the Director of Nursing said the following:-The resident required one-on-one supervision in the past, but was on 15-minute face checks at the time of the altercation with Resident #2;-She considered Resident #1 striking Resident #2 as abuse;-Resident #2 suffered lacerations above his/her right eye and upper lip that required sutures. During interview on 12/3/25 at 1:30 P.M., the Administrator said the following:-She believed the interventions in place to protect others from Resident #1 were effective, until they were not on 11/10/25 when Resident #1 suddenly hit Resident #2;-Resident #1 said Resident #2 said something to him/her, but Resident #2 had not;-Resident #1's behavior was unpredictable;-Resident #2 received a busted lip that required sutures as a result of the altercation;-She felt any type of hitting was considered abuse. Complaint # 2664800

Based on observation, interview, and record review, the facility failed to protect one resident (Resident #1), in a sample of seven residents, from physical abuse by another resident, (Resident #3), who had a history of aggressive behaviors. Staff failed to separate the residents and sufficiently monitor Resident #3 after he/she had initially verbally assaulted Resident #1. Resident #3 was able to return to the dining area and physically assault Resident #1. Resident #1 received scratches and had a large clump of hair pulled from his/her scalp. The facility census was 117. Review of the facility policy, Resident's Rights, dated (revised) 07/05/23, showed the facility must protect and promote rights of each resident, including freedom from verbal, sexual, mental and physical abuse, corporal punishment and involuntary seclusion. Review of the facility policy, Abuse and Neglect, dated (revised 06/12/24), showed the following: -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations; -The facility will take steps to prevent mistreatment while the investigation is underway; -Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents and employees in the facility. 1. Review of Resident #1's face sheet, undated, showed he/she had a legal guardian. Review of the resident's care plan, dated 08/07/24, showed no issues with behavioral symptoms, verbal or physical, directed at others. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 08/09/24, showed the following: -Cognitively intact; -Diagnoses included hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held contrary to reality); -No behavioral symptoms, verbal or physical, directed at others; -Use of antipsychotics (a medication to help reduce psychotic symptoms like hallucinations, delusions, and disordered thinking), antianxiety, and antidepressant medications. During an interview on 09/04/24 at 11:40 A.M., the resident said the following: -A couple of days ago, he/she was frustrated that Resident #3 was in the hallway outside his/her room, and on the facility resident phone for a long period of time, when he/she (Resident #1) had expected a call from his/her family; -He/She asked Resident #3 to get off the phone and Resident #3 became angry, started yelling at him/her, threw the phone down and then called him/her (Resident #1) a bad name; -The activity director was in the dining room and told Resident #3 to go to his/her room to calm down and he/she did, but he/she did not stay there; -He/She walked into the dining room and Resident #3 came up to him/her and threw his/her shoulder into him/her (Resident #1), scratched his/her neck and pulled a clump of his/her hair out; -The activity director and another staff person responded to the incident and shielded him/her with her arms, while another staff pulled Resident #3 off him/her; -The activity director took him/her to her office for the afternoon and Resident #3 stayed on the unit; -He/She was upset and afraid after Resident #3 attacked him/her; -He/She and Resident #3 were still on the same unit but avoided each other now. Observation on 09/04/24 at 11:45 A.M. showed the following: -Resident #1 had a mildly red, linear scratch on the back of his/her neck, measuring approximately six inches in length and less than two millimeters in width; -The resident had a clump of brown hair wrapped up in a paper towel in his/her pocket that measured about the size of a half-dollar; -The resident had a small area of baldness along the left side of the scalp, and it measured about two inches in width by two inches in length. During an interview on 09/11/24 at 11:30 A.M., the resident's legal guardian said Resident #1 did not have a history of verbal or physical aggression towards other residents. 2. Review of Resident #3's face sheet, undated, showed he/she had a legal guardian. Review of the resident's electronic medical record showed a Pre-Admission Screening and Resident Review Level Two (PASARR II), dated 08/30/23, showed the following: -The resident was discharged from a previous skilled nursing facility due to aggression and the facility filed charges and a restraining order against him/her; -The resident was unable to live in a less-restrictive environment at this time for his/her safety and the safety of others, he/she required 24-hour supervision; -Diagnoses included major depressive disorder, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), generalized anxiety disorder, and post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event); -The resident's legal guardian said the resident had a history of aggressive behaviors when he/she was frustrated or when he/she felt his/her needs were not being met; -Behaviors to be addressed in the nursing facility plan of care included attention seeking behaviors, irritability, anxiety, outbursts, and per hospital records, history of aggressive behavior when the resident is frustrated or when he/she felt his/her needs were not being met. Review of the resident's baseline care plan, dated 08/12/24, showed no documentation regarding behaviors, interventions or PASARR II recommendations related to the resident's behaviors. Review of the resident's admission MDS, completed by the facility staff and dated 08/25/24, showed the following: -Cognitively intact; -Diagnoses included hallucinations and delusions; -No behavioral symptoms; -Use of antipsychotic, antianxiety and antidepressant medications. During an interview on 09/04/24 at 1:10 P.M., the resident said the following: -A couple of days ago, he/she was on the phone in the hallway when Resident #1 accused him/her of being on the phone for too long and it made him/her (Resident #3) mad; -He/She had problems in the past of acting out when he/she was mad; -He/She might have cussed at Resident #1, he/she was not sure; -The facility staff told him/her to go to his/her room and he/she did for maybe 15 minutes and then he/she went to the dining room; -Resident #1 hit him/her first on the chest when he/she went to the dining room, so he/she pulled Resident #1's hair; -A staff person pulled him/her off Resident #1 and told him/her (Resident #3) to go to his/her room; -Staff put him/her on 1:1 monitoring (one staff monitored the resident exclusively) and stayed with him/her for a little bit; he/she was not sure how long; -He/She was still on the same unit as Resident #1 and he/she just stayed away from Resident #1 now. During an interview on 09/04/24 at 2:15 P.M., the activity director said the following: -On 09/02/24, around 9:30 A.M., she was in the dining room when Resident #3 began yelling and cussing at Resident #1 because Resident #1 complained Resident #3 had been on the resident phone for too long; -She and another staff member told Resident #3 to calm down because Resident #3 was yelling and cussing at Resident #1, and she (the activity director) told Resident #3 to go to his/her room; -Resident #3 started yelling and cussing at her (the activity director) and another staff member, while Resident #3 walked to his/her room; -She thought the situation was resolved because Resident #3 went to his/her room, staff did not follow Resident #3 to his/her room and did not stay with him/her; -Resident #3 returned to the dining area in a few minutes and used his/her shoulder to shove Resident #1 and then started to pull Resident #1's hair; -She called a code green (indicating additional staff were needed due to a resident was a threat to himself/herself or to others) when Resident #3 was physically aggressive towards Resident #1; -She and Licensed Practical Nurse (LPN) A separated the residents; she put her arms around Resident #1 because Resident #3 was still pulling at Resident #1's hair; -LPN A pulled Resident #3 off Resident #1; -She took Resident #1 to her office and off the unit for the afternoon so Resident #1 could calm down; -Resident #1 was initially teary and told her he/she was in shock, but then Resident #1 said he/she was calmer and he/she went back to the unit later in the afternoon; -Resident #3 remained on the unit; she (the activity director) was not sure if staff stayed with Resident #3 after the incident occurred; -She was aware of Resident #3's history of aggression. During an interview on 09/18/24 at 8:40 A.M., LPN A said the following: -On 09/02/24, Resident #3 was on the phone in the dining room (of the 400-500-600 unit) when Resident #1 started complaining because he/she wanted to use the phone; -He/She did not remember what the residents said to each other, but he/she knew the residents were in an argument by the tone of their voices; -He/She told the residents to separate, and the activity director took Resident #1 off the unit and LPN A told Resident #3 to go to his/her room; -He/She could not remember if any other staff went with Resident #3 to his/her room; -Resident #1 returned to the unit with the activity director, he/she could not remember how long Resident #1 was gone; -Resident #3 came out of his/her room and was not calmed down yet, LPN A could not remember how he/she knew Resident #3 was not calm; -Resident #3 went up to Resident #1 and pushed him/her and then pulled his/her hair; -LPN A and another staff member got in between Resident #1 and Resident #3 to separate them, but he/she could not remember which staff helped him/her separate the residents; -He/She could not remember if a code green was called; -Resident #1 was taken off the unit by the activity director again and LPN A thought Resident #3 was taken to his/her room by a certified nurse assistant (CNA), he/she could not remember; -He/She did not think Resident #1 and Resident #3 had any physical injuries but he/she could not remember if he/she did a physical assessment of the residents; -If he/she had done a physical assessment of the residents, he/she would have documented the assessment in the electronic medical record (EMR); -He/She could not remember if he/she documented the events that occurred between Resident #1 and Resident #3 in the EMR; -He/She could not remember if he/she reported the events that occurred between Resident #1 and Resident #3 to administration; -He/She was not sure if the verbal exchange between Resident #1 and Resident #3 was abuse since he/she did not actually hear what was said; -He/She said physical altercations between residents would be considered resident-to-resident abuse. During an interview on 09/11/24 at 2:15 P.M., the resident's legal guardian said the following: -The resident had a long history of aggression that could be unprovoked; -The facility should have been aware of the resident's past behaviors of aggression and poor coping skills; -It was important for the facility to include in the resident's care plan, his/her history of aggressive behavior when frustrated. During an interview on 09/04/24 at 3:45 P.M., the director of nurses (DON) said the following: -She was not aware of the verbal or physical altercation that occurred between Resident #1 and Resident #3 on 09/02/24; -She was aware of Resident #3's history of aggression and poor coping skills, but was not aware if Resident #3 had any behaviors at the prior facility before the resident's arrival in the last couple of weeks; -She would have expected staff to separate the residents and provide protection for Resident #1 when Resident #3 began to verbally assault him/her; -If staff had provided a 1:1 with Resident #3 when he/she was verbally aggressive, it may have prevented the physical assault of Resident #1; -The residents involved should have been separated while an investigation of the incident took place. During an interview on 09/04/24 at 5:30 P.M., the administrator said the following: -She was aware that there was a verbal altercation between Resident #1 and another resident on 09/02/24; -She thought Resident #1 left the unit with the activity director after the verbal altercation with Resident #3; -She was not aware that Resident #3 physically attacked Resident #1; -She was aware that Resident #3 had a history of aggression; it was in his/her PASARR II; -If staff had provided a 1:1 with Resident #3 when he/she was verbally aggressive with Resident #1, it may have prevented the physical assault of Resident #1 by Resident #3; -The residents involved should have been separated while an investigation of the incident took place. #MO00241466

Based on observation, interview and record review, the facility failed to assess three residents (#19, #47, and #115) for the ability to consent prior to having sexual relations and failed to protect one resident (Resident #47) from sexual abuse by a resident (Resident #115). Resident #47 reported feeling worthless, having a flashback, and fear of contracting STDs (Sexual Transmitted Diseases). A sample of fourteen residents was selected for review. The facility census was 115. Review of the facility's Sexual Activity/Abuse and Neglect Policy, last reviewed 4/18/22, showed the following: -The purpose of this policy is to ensure the facility provides protective oversight and care for all residents requesting to engage in sexual activity/intercourse while at the same time protecting their rights; -Residents that are wishing to engage in sexual activity/intercourse will be allowed to participate in these activities as long as both parties consent and have the ability to consent. Non-consensual acts and acts that impact negatively on the resident community, such as public displays, shall not be allowed; -Determination of ability to consent: -a. If the resident has a guardian or a physical and/or cognitive impairment, an assessment should be completed to determine the resident's ability to consent. This assessment will be completed by the Interdisciplinary Care Team (ICT), with the assistance of the resident's physician and/or psychiatrist as needed. The assessment shall include an awareness of the relationship including awareness of who is initiating the relationship, identity of the other person, and comfort level with sexual intimacy, the ability to avoid exploitation including the resident's values and ability to refuse unwanted advances; and an awareness of potential risk associated with the relationship, including STDs or pregnancy, if applicable, or reaction if the relationship ends; -The resident's guardian (if applicable) will be invited to provide their guidance/opinion to the ICT. Family members may be involved in the assessment as appropriate; -b. All documentation regarding the resident's ability to consent shall be maintained in the resident's medical file and, if appropriate, in the resident's care plan; -Residents will be assessed for the capacity to consent to sexual activity if they have a history of sexual activity, have indicated that they wish to engage in sexual activity, or if the facility or guardian otherwise believes that they should be assessed. All residents do not need to be assessed. Residents will be reassessed as needed; -If a resident has been deemed to be unable to consent to sexual activity, the resident will be told that they are not permitted to engage in sexual activity; -Employees will not allow sexual activity to take place unless both residents have been deemed to have the capacity to consent; -If non-consensual sexual activity occurs, the abuse and neglect policy will be followed. Review of the facility's Abuse and Neglect Policy, last reviewed 1/05/23, showed the following: -Sexual abuse is non-consensual contact of any type with a resident. Sexual abuse includes, but is not limited to, the following: a. Unwanted intimate touching of any kind especially of the breasts or perineal area; b. All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; This also includes failure to intervene or attempt to stop or prevent non-consensual sexual activity or performance between residents; -The facility is committed to protection of our residents from abuse by anyone including, but not limited to, Facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals; -As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis; -Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents and employees in the facility. Review of the facility's Covenant Guidelines, dated 10/12/22, showed the following: -Residents residing on Station 2, after administrative approval, may visit other residents of the same gender with the approval from staff working the unit and that of the roommate in the room being visited as long as there are no guardian limitations and charge nurse is aware. Door must be open while visiting and the light on if dark; -Any and all visits in other resident rooms/stations will be determined by guardian limitations before the ICT makes a determination for approval. ICT to review and make recommendations to the guardians if they feel the resident has displayed appropriate behaviors during a set time frame to be determined by the ICT; -Residents who have legal guardians will follow all legal guardian imposed limitations as outlines in their individualized plan of care; -All guidelines were discussed with a committee of residents, staff, a guardian, and the ombudsman. The guidelines were voted on by the residents, with the majority being the final decision. All limitations may be modified by an individual resident's guardian should there be the need; -These covenants are not negotiable, and are put into place and enforced for the safety of the residents/staff and the facility. 1. Review of Resident #47's Pre Admission Screening and Resident Review Level Two (PASARR II), dated 7/05/13, showed the following: -Diagnoses included mood disorder (a mental health condition that primarily affects your emotional state), impulse control disorder (a group of behavioral conditions that involve an inability to control impulses and behaviors), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life), major depression (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), mixed personality disorder (the occurrence of traits of more than one personality disorder), borderline personality disorder (a mental illness that severely impacts a person's ability to manage their emotions), and mild mental retardation (deficits in intellectual functions pertaining to abstract/theoretical thinking); -The resident communicates without problem/expresses self well; -Cognitively the resident does not make good decisions and cannot follow complex directions; -He/She had a cooperative, childlike manner which he/she was guarded, easily frustrated, and easily distracted; -The resident required monitoring, 24 hours per day supervision and support due to limited intellectual disability, impaired judgement, and history of being taken advantage of; -He/She required redirection for inappropriate behaviors and support for increased anxiety; -The resident would benefit from short term nursing facility level of service for stabilization of mood; -If admitted to a nursing facility, he/she would need implementation of systematic plans to change inappropriate behavior, medication therapy/monitoring to change inappropriate behavior or alter manifestations of psychiatric illness, provision of structured environment, and development of personal support networks. Review of the resident's care plan, dated 7/09/22 showed the following: -The resident has a guardian to assist in decision making due to mental illness (dated 7/09/22); -Ensure guardian wishes are followed (dated 7/09/22); -Encourage resident to participate in social situations and monitor interactions with others (dated 7/09/22); -Resident can be childlike in demeanor. Review of the facility's guardian limitations report dated 12/22/23, showed the resident must follow covenant guidelines. Review of the resident's progress notes dated 2/11/24 at 1:52 P.M., showed the following: -The resident was noted to hold hands and be flirtatious with a peer. The resident was educated on proper friendly boundaries and not having guardian permission for relationships; -The resident acknowledged understanding and said he/she would be friends until guardian approves otherwise with no signs and symptoms of pressure or distress from peer; -Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Resident Care Coordinator aware. Review of the resident's care plan, revised on 2/21/24 showed the following: -The resident experienced flirtation with a peer and needs reminding to maintain platonic friendship and refrain from physical touching, kissing, hand holding, etc.; -He/She needs reminders not to enter peers' rooms without invitation or staff permission and was not to be on the 400 hall or a hall that he/she does not live on. Review of the resident's medical record from admitted to 1/2/24, showed no assessment for the resident to consent to sexual activity. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/20/24, showed the resident was cognitively intact. During an interview on 4/24/24 at 11:41 A.M. and 4/25/24 at 10:24 A.M., the resident said the following: -He/She thought Resident #115 had been admitted to the facility around 1/2/24; -He/She had been in a relationship with Resident #115 for about two months; -He/She told Resident #115 he/she was thinking of moving closer to his/her family and Resident #115 told him/her he/she did not want him/her to move as he/she truly liked him/her as a friend, but liked him/her more as a lover; -He/She had performed oral sex on Resident #115 two times, once after supper and once before lunch, and both times the act took place in Resident #115's room; -Resident #115 came to his/her room and asked him/her to give him/her oral sex, so they went to Resident #115's room; -He/She had agreed to perform oral sex, but told Resident #115 he/she did not want to complete the act. Resident #115 held his/her head in place so he/she could not move and did it anyway; -His/Her guardian told him/her he/she could not be in a relationship with Resident #115 or anyone else; -This all occurred after supper and right before shift change; -The second time he/she gave Resident #115 oral sex it happened the same way, even though he/she had asked him/her not to complete the act, Resident #115 did not listen and did it anyway without his/her permission; -The second occurrence happened after the 1:30 P.M. smoke break, when staff were outside with smokers; -He/She did not want to give Resident #115 oral sex a second time, but he/she wanted to keep him/her as a friend and felt obligated to give him/her oral sex; -He/She said Resident #115 said this was their little secret and he/she should not tell anyone what they are doing. -After the second time he/she gave Resident #115 oral sex, Resident #115 was in his/her bed and Certified Nurse Aide (CNA) E walked into the room; -CNA E told them if they want to be in each other's rooms, they knew the rules and the door should be open and reminded them if it was night the light had to be turned on; -The reason he/she waited so long to talk about it, he/she did not know he/she could get into trouble. He/She did not want to get Resident #115 into trouble; -He/She told the DON he/she wanted to be tested for STDs; -He/She did not have any physical injuries, but has had a flash back and woke up the night before sweating. He/She said he/she was dreaming and when he/she woke up he/she felt worthless. Review of the resident's written statements for the facility, dated 4/21/24, showed the following: -The resident had sexual relations with Resident #115; -Resident #115 forced him/herself on him/her by making the resident give him/her oral sex; -Both residents were caught by CNA E; -The resident told the Administrator about the incidents which happened in late January early February; -The resident told the Administrator he was worried about getting AIDS. During an interview on 4/26/24 at 11:09 A.M., CNA E said the following: -The day Residents #47 and #115 were caught sitting on Resident #115's bed, the door was closed and when he/she opened the door he/she found the two residents sitting on Resident #115's bed, staring into each other's eyes and he/she reminded them to keep things in the friend zone; -He/She left her job around 3/15/24 and management had a meeting with Resident #47 and #115's guardian and there was no consent obtained at that time for a physical relationship. During an interview on 4/24/24 at 1:33 P.M., the resident's Caseworker D said the following: -The facility had reported Resident #47 had been forced to perform oral sex on another resident back in January; -He/She did not feel the resident had the mental capacity to be in a relationship. During an interview on 4/30/24 at 2:41 P.M., the resident's legal guardian C said the following: -He/She was not aware the resident and Resident #115 had been in a relationship; -In order for him/her to consent for the resident to be in a relationship, he/she would have needed to have had a conversation with the facility on an as needed basis when these issues arise. Review of the resident's Capacity to Consent to Sexual Activity Form, dated 4/22/24, showed the following: -The resident could not say what level of sexual intimacy he/she would be comfortable with; -The resident did not have the capacity to say no to uninvited sexual contact; -The resident could not describe how he/she would react when the relationship ended; -The resident had been assessed, for the purpose of determining whether he/she is capable of understanding the purpose, nature, risks, benefits, and alternatives (including nonparticipation) in giving consent, making a decision about participation, and understanding that the decision about participation in the sexual activity, otherwise entitled: Capacity to Consent to Sexual Activity; -On the basis of this examination the evaluator arrived at the conclusion that this participant clearly lacks this capacity at this time; -The resident signed the document along with the evaluator, the ADON and the Social Services Director (SSD). 2. Review of Resident #115's PASARR II, dated 11/15/23, showed the following: -Diagnoses included oppositional defiant disorder (a type of behavior disorder. It is mostly diagnosed in childhood in which individuals show a pattern of uncooperative, defiant, and hostile behavior toward peers, parents, teachers, and other authority figures), attention-deficit hyperactivity disorder (ADHD) (neurodevelopmental disorders usually first diagnosed in childhood and often lasts into adulthood in which individuals have trouble paying attention or controlling impulsive behaviors (may act without thinking about what the result will be or be overly active), borderline intellectual functioning (a group of people who function on the border between normal intellectual functioning and intellectual disability), bipolar disorder, autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), moderate intellectual disabilities, intellectual disability moderate to severe (Individuals with moderate intellectual disability possess basic communication skills and can maintain self-care, often with some degree of support. Those with a severe intellectual disability exhibit considerable developmental delays), pervasive developmental disorder (characterized by delays in the development of social and communication skills), learning disorder, developmental disorder of scholastic skills (include dyscalculia (difficulty learning arithmetic) but also dyslexia (a condition of neurodevelopmental origin that mainly affects the ease with which a person reads, writes, and spells, typically recognized as a specific learning disorder in children), mood disorder, Post Traumatic Stress Disorder (PTSD) (a real disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), disruptive mood dysregulation disorder (condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts), and impulse control disorder with recurrent self-harm; -He/She needs nursing facility placement due to behavioral difficulties and/or mental illness symptoms requiring 24 hour monitoring/management; -His/Her individual limitations include intellectually disability, poor insight/judgment, and limited interpersonal support system; -His/Her individual strengths include guardianship in place and he/she is able to make his/her wants/needs known; -He/She needs a structured environment in order to assess and plan for the level of supervision required to prevent harm to his/herself or to others; -He/She requires ongoing assessment of mood, thought process and behaviors for early recognition of changes to promote early intervention and proactive modifications to plan of care. Review of the facility's guardian limitations report dated 12/22/23, showed the resident was to follow covenant guidelines. Review of the resident's care plan, dated 2/03/24 and revised 2/20/24, 4/23/24 and 4/24/24, showed the following: -Problem: The resident has a history with extensive psychiatric history, including oppositional defiant disorder, ADHD, bipolar disorder, depression, anxiety, suicidal ideation with attempts of self-harm, moderate to severe intellectual disabilities including autism (varying with hospitalization s and placements), PTSD, with symptoms including anxiety, labile mood, hopelessness, worthlessness, loss of appetite, fearfulness, aggressive and assaultive behavior, paranoia, perseveration, defiance, poor concentration, lack of insight and poor judgement (dated 2/03/24); -Problem: The resident has manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. These behaviors include hypersexuality, seeking sexual relationship from peers (dated 2/20/24); -Intervention: He/She continues to be advised to refrain from physical contact intimacy. Discussed alternatives including masturbating privately and seeking assist to procure device to aid in such if desired. Review of the resident's progress notes, dated 2/11/24, showed the resident was noted to hold hands and be flirtatious with a peer. Resident educated on proper friendly boundaries and not having guardian permission for relationships. Resident acknowledged understanding and states will be friends until guardian approves otherwise with no signs or symptoms or pressure or distress from peer. Review of the resident's admission MDS, completed by facility staff, dated 2/14/24, showed the resident had moderately impaired cognition. Review of the facility clinical census, dated 3/17/24, showed the resident was moved to another hall. Review of the resident's progress notes dated 4/01/24 at 1:04 A.M., showed the resident attended 7:30 P.M. supervised smoke break and when finished he/she went to common area to sit at a table with peer (Resident #19). The resident got up from the table a couple of minutes later, and approached the peer at the same table. The resident leaned over and kissed the peer on the lips. Staff immediately intervened and educated resident on facility guidelines of no physical contact with other peers. DON, Administrator. and guardian notified. Review of the resident's progress notes dated 4/06/24 at 4:11 A.M., showed the resident became upset when redirected from peer, and became belligerent. Staff counseled the resident on guidelines and the resident walked away. The resident then friended a new peer. Was seen chatting and following new peer. Review of the resident's facility acquired written statement dated 4/21/24, showed the following: -He/She and Resident #47 were having sex, kissing, making out and were caught by CNA E in his/her bed together; -He/She and Resident #47 engaged in oral sex and kissed behind the building; -The sexual acts were done out of love; -He/She has a new boy/girlfriend and Resident #47 was jealous and has been trying to cause problems with his/her new relationship. During an interview on 4/24/24 at 12:15 P.M. and 4/25/24 at 11:38 A.M. and 12:14 P.M., the resident said the following: -He/She was not currently in a physical relationship, but he/she was in an emotional relationship with Resident #19; -He/She used to be boy/girlfriend with Resident #47; -He/She did not force Resident #47 to have oral sex, it was consensual and happened many times in each of their rooms; -He/She had oral sex with Resident #47 about two to three months ago; -He/She did not have permission from his/her guardian to have a relationship with anyone; -He/She started a relationship with Resident #19 about one month ago and had oral sex, but now cannot do anything until guardians give them permission. Review of the Resident's Capacity to Consent to Sexual Activity Form, dated 4/22/24, showed the following: -The resident was not aware of who was initiating sexual contact; -The resident could not state what level of sexual intimacy he/she would be comfortable with; -The residents' behavior was not consistent with formerly held beliefs/values; -The resident could not describe how he/she would react when the relationship ended; -The resident had been assessed, for the purpose of determining whether he/she is capable of understanding the purpose, nature, risks, benefits, and alternatives (including nonparticipation) in giving consent, making a decision about participation, and understanding that the decision about participation in the sexual activity, otherwise entitled: Capacity to Consent to Sexual Activity; -On the basis of this examination, the evaluator arrived at the conclusion that this participant clearly lacks this capacity at this time; -The resident signed the document along with the evaluator, the ADON and the SSD. During an interview on 4/24/24 at 1:43 P.M., the resident's legal guardian A said the following: -He/She was not aware Resident #115 was in a physical relationship; -He/She did not think the resident understood what it meant to be in a healthy relationship as he/she does not believe the resident ever witnessed a healthy relationship; -The issue with giving permission for a relationship never came up for Resident #115. 3. Review of Resident #19's PASARR Level II dated 9/07/18 showed the following: -Diagnoses included: Mood disorder, impulse control disorder, schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions which include delusions (false beliefs), hallucinations (seeing or hearing things that don't exist), unusual physical behavior, and disorganized thinking and speech.), PTSD, adjustment disorder, ADHD, major depressive disorder (when an individual has a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, agitation, sleep disturbances, or suicidal thoughts.) (MDD), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), bipolar disorder, borderline personality disorder, developmental delay, history of traumatic brain injury (a sudden injury that causes damage to the brain); -Historical symptoms or behaviors included seeing a psychiatrist around the age of seventeen due to depression, auditory and visual hallucinations following the death of his/her adopted father. He/She was hospitalized around the age of twenty due to suicidal ideation. He/She has attempted suicide several times in the past. He/She has self-mutilating behaviors with numerous scars on lower legs where he/she cut, burned, scratched, or otherwise hurt him/herself. He/She has chronic suicidal ideation's as he/she hears voices telling him/her to kill him/herself, paranoid thoughts, and elopement from facility; -He/She has had numerous hospitalization s for depression and suicidal ideations; -He/She requires secured/behavioral unit; -His/Her thought process/cognitive status included poor concentration, poor judgement, tangential (a communication disorder in which the train of thought of the speaker wanders and shows a lack of focus, never returning to the initial topic of the conversation), disorganized, short term memory deficit, and poor insight; -His/Her manner was cooperative and childlike; -He/She requires a nursing facility due to ongoing for safety, medication, medical and psychiatric monitoring and requires ongoing medical management and review of medications; -He/She does not make good or safe decisions. Review of the resident's care plan, initiated 5/23/22 and revised on 4/29/23, showed the following: -Problem: PASRR showed the resident had a history of behavioral challenges that require protective oversight in a secure setting. He/She began experiencing hallucinations at seventeen after the death of his/her adopted father. He/She experienced auditory and visual command hallucinations as well as suicidal and homicidal ideation. He/She has a history of suicide attempts. He/She also practiced self-mutilation by cutting self, leaving numerous scars. He/She has a diagnoses of schizoaffective and mood disorder, anxiety, major depression, and psychosis (dated 5/23/22); -Problem: The resident has a history of PTSD. PTSD affects the resident symptoms and may flare up without any known trigger. Alterations in reactivity from the traumatic event, including aggressiveness, and self-destructive behavior. Intrusion or persistently re-experienced stressors in at least one of the following ways: recurrent memories, traumatic nightmares, flashbacks, prolonged distress following traumatic reminders, significant physical symptoms after exposure to stressors. The resident states he/she was bullied in school, physically and emotionally. Triggers include loud noises, accusing him/her of doing things and unwanted touching (dated 4/29/23). Review of the facility's guardian limitations report, dated 12/22/23, showed the following: -The resident must follow covenant guidelines; -The resident may not have any relation with opposite sex peers. Review of the resident's quarterly MDS, completed by facility staff, dated 3/03/24, showed the resident was cognitively intact. Review of the resident's progress notes, dated 4/01/24 at 1:20 A.M., showed the following: -Resident attended 7:30 P.M. supervised smoke break, and when finished, went to common area and sat at a table with peer. A couple of minutes later, the peer (Resident #115) got up from table and kissed this resident. Staff immediately intervened and educated resident on facility guidelines of no physical contact with other peers. DON and Administrator notified. Left message on voicemail for guardian. Review of the resident's guardian email, dated 4/03/24 at 9:16 A.M. and 4/03/24 at 12:48 P.M., showed the following: -The email was sent to the SSD; -The guardian would like to make the facility aware of this guardian directive. The resident is not to be in a relationship with anyone (male or female). Relationships always cause him/her to become confused and when they end he/she becomes suicidal. The resident can have friends, but no romantic relationships. There should be no public display of affection between the resident and another resident. Review of the resident's progress notes, dated 4/06/24 at 5:34 A.M., showed the resident became upset at staff for redirecting him/her away from another peer. Resident became verbally aggressive, but was easily redirected. During an interview on 4/24/24 at 11:31 A.M., 4/24/24 at 4:08 P.M. and 4/25/24 at 11:46 A.M. and 12:16 P.M., the resident said the following: -He/She had consensual oral sex in Resident #115's room about one and a half weeks ago; -He/She can only be with Resident #115 in the dining room and on smoke breaks; -He /She can kiss and hold hands with Resident #115; -He/She just wanted to do a favor for Resident #115, because he/she said he/she was horny. Review of the resident's Capacity to Consent to Sexual Activity Form, dated 4/22/24, showed the following: -The resident's behavior was not consistent with formerly held beliefs/values; -The resident did not realize that the relationship may be time limited due to placement of male/female on unit was temporary; -The resident could not describe how he/she would react when the relationship ended; -The resident had been assessed, for the purpose of determining whether he/she is capable of understanding the purpose, nature, risks, benefits, and alternatives (including nonparticipation) in giving consent, making a decision about participation, and understanding that the decision about participation in the sexual activity, otherwise entitled: Capacity to Consent to Sexual Activity; -On the basis of this examination the evaluator arrived at the conclusion that there was doubt about this participant's capacity at this time and further evaluation was necessary; -The resident signed the document along with the evaluator, the ADON and the SSD. Observation on 4/24/24 at 4:02 P.M. showed Resident #115 knocked on the resident's door while the surveyor interviewed the resident. Resident #115 was not supposed to be allowed on the hall as he/she did not live on the hall. During an interview on 4/24/24 at 1:57 P.M. and 5/01/24 at 12:21 P.M., the resident's legal guardian B said the following: -He/She did not want Resident #19 to have any relationships; -He/She felt the resident did not have the capacity to consent to a relationship of any kind; -There had been times in the past when Resident #19 has been in a relationship and when it ended he/she was taken to the hospital for suicidal ideations; -He/She felt the resident could not handle any breakup without it causing suicidal ideations; -He/She emailed a directive to the facility on [DATE] stating the resident could not have a boy/girlfriend relationships; -The resident does not know what a relationship was because he/she has never been in a loving relationship; -The resident can be easily taken advantage of by anyone dealing with anything, for example, there were other residents who were trying to get his/her coloring books and pencils and a fight would ensue; -When he/she spoke with the resident on the phone he/she had told him/her that he/she had a boy/girlfriend and he/she told him he/she did not agree and that he/she knew what could happen if/when the relationship ended; -He/She sent the email on 4/03/24, because the resident told him/her he/she was in love with another resident; -His/Her family member called after speaking with the resident to report he/she was afraid the resident was going away with Resident #115 to another family 's home in another city; -He/She then contacted the resident and told him/her he/she could not have a relationship with anyone; -He/She felt romantic relationships could cause the resident to harm him/herself as the resident does not handle his/her feelings very well when relationships come to an end; -He/She did not expect or approve of the resident having/giving o

Based on observation, interview and record review, the facility failed to assess three residents (#19, #47, and #115) for the ability to consent prior to having sexual relations and failed to protect one resident (Resident #47) from sexual abuse by a resident (Resident #115). Resident #47 reported feeling worthless, having a flashback, and fear of contracting STDs (Sexual Transmitted Diseases). A sample of fourteen residents was selected for review. The facility census was 115. Review of the facility's Sexual Activity/Abuse and Neglect Policy, last reviewed 4/18/22, showed the following: -The purpose of this policy is to ensure the facility provides protective oversight and care for all residents requesting to engage in sexual activity/intercourse while at the same time protecting their rights; -Residents that are wishing to engage in sexual activity/intercourse will be allowed to participate in these activities as long as both parties consent and have the ability to consent. Non-consensual acts and acts that impact negatively on the resident community, such as public displays, shall not be allowed; -Determination of ability to consent: -a. If the resident has a guardian or a physical and/or cognitive impairment, an assessment should be completed to determine the resident's ability to consent. This assessment will be completed by the Interdisciplinary Care Team (ICT), with the assistance of the resident's physician and/or psychiatrist as needed. The assessment shall include an awareness of the relationship including awareness of who is initiating the relationship, identity of the other person, and comfort level with sexual intimacy, the ability to avoid exploitation including the resident's values and ability to refuse unwanted advances; and an awareness of potential risk associated with the relationship, including STDs or pregnancy, if applicable, or reaction if the relationship ends; -The resident's guardian (if applicable) will be invited to provide their guidance/opinion to the ICT. Family members may be involved in the assessment as appropriate; -b. All documentation regarding the resident's ability to consent shall be maintained in the resident's medical file and, if appropriate, in the resident's care plan; -Residents will be assessed for the capacity to consent to sexual activity if they have a history of sexual activity, have indicated that they wish to engage in sexual activity, or if the facility or guardian otherwise believes that they should be assessed. All residents do not need to be assessed. Residents will be reassessed as needed; -If a resident has been deemed to be unable to consent to sexual activity, the resident will be told that they are not permitted to engage in sexual activity; -Employees will not allow sexual activity to take place unless both residents have been deemed to have the capacity to consent; -If non-consensual sexual activity occurs, the abuse and neglect policy will be followed. Review of the facility's Abuse and Neglect Policy, last reviewed 1/05/23, showed the following: -Sexual abuse is non-consensual contact of any type with a resident. Sexual abuse includes, but is not limited to, the following: a. Unwanted intimate touching of any kind especially of the breasts or perineal area; b. All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; This also includes failure to intervene or attempt to stop or prevent non-consensual sexual activity or performance between residents; -The facility is committed to protection of our residents from abuse by anyone including, but not limited to, Facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals; -As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis; -Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents and employees in the facility. Review of the facility's Covenant Guidelines, dated 10/12/22, showed the following: -Residents residing on Station 2, after administrative approval, may visit other residents of the same gender with the approval from staff working the unit and that of the roommate in the room being visited as long as there are no guardian limitations and charge nurse is aware. Door must be open while visiting and the light on if dark; -Any and all visits in other resident rooms/stations will be determined by guardian limitations before the ICT makes a determination for approval. ICT to review and make recommendations to the guardians if they feel the resident has displayed appropriate behaviors during a set time frame to be determined by the ICT; -Residents who have legal guardians will follow all legal guardian imposed limitations as outlines in their individualized plan of care; -All guidelines were discussed with a committee of residents, staff, a guardian, and the ombudsman. The guidelines were voted on by the residents, with the majority being the final decision. All limitations may be modified by an individual resident's guardian should there be the need; -These covenants are not negotiable, and are put into place and enforced for the safety of the residents/staff and the facility. 1. Review of Resident #47's Pre admission Screening and Resident Review Level Two (PASARR II), dated 7/05/13, showed the following: -Diagnoses included mood disorder (a mental health condition that primarily affects your emotional state), impulse control disorder (a group of behavioral conditions that involve an inability to control impulses and behaviors), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life), major depression (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), mixed personality disorder (the occurrence of traits of more than one personality disorder), borderline personality disorder (a mental illness that severely impacts a person's ability to manage their emotions), and mild mental retardation (deficits in intellectual functions pertaining to abstract/theoretical thinking); -The resident communicates without problem/expresses self well; -Cognitively the resident does not make good decisions and cannot follow complex directions; -He/She had a cooperative, childlike manner which he/she was guarded, easily frustrated, and easily distracted; -The resident required monitoring, 24 hours per day supervision and support due to limited intellectual disability, impaired judgement, and history of being taken advantage of; -He/She required redirection for inappropriate behaviors and support for increased anxiety; -The resident would benefit from short term nursing facility level of service for stabilization of mood; -If admitted to a nursing facility, he/she would need implementation of systematic plans to change inappropriate behavior, medication therapy/monitoring to change inappropriate behavior or alter manifestations of psychiatric illness, provision of structured environment, and development of personal support networks. Review of the resident's care plan, dated 7/09/22 showed the following: -The resident has a guardian to assist in decision making due to mental illness (dated 7/09/22); -Ensure guardian wishes are followed (dated 7/09/22); -Encourage resident to participate in social situations and monitor interactions with others (dated 7/09/22); -Resident can be childlike in demeanor. Review of the facility's guardian limitations report dated 12/22/23, showed the resident must follow covenant guidelines. Review of the resident's progress notes dated 2/11/24 at 1:52 P.M., showed the following: -The resident was noted to hold hands and be flirtatious with a peer. The resident was educated on proper friendly boundaries and not having guardian permission for relationships; -The resident acknowledged understanding and said he/she would be friends until guardian approves otherwise with no signs and symptoms of pressure or distress from peer; -Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Resident Care Coordinator aware. Review of the resident's care plan, revised on 2/21/24 showed the following: -The resident experienced flirtation with a peer and needs reminding to maintain platonic friendship and refrain from physical touching, kissing, hand holding, etc.; -He/She needs reminders not to enter peers' rooms without invitation or staff permission and was not to be on the 400 hall or a hall that he/she does not live on. Review of the resident's medical record from admission date to 1/2/24, showed no assessment for the resident to consent to sexual activity. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/20/24, showed the resident was cognitively intact. During an interview on 4/24/24 at 11:41 A.M. and 4/25/24 at 10:24 A.M., the resident said the following: -He/She thought Resident #115 had been admitted to the facility around 1/2/24; -He/She had been in a relationship with Resident #115 for about two months; -He/She told Resident #115 he/she was thinking of moving closer to his/her family and Resident #115 told him/her he/she did not want him/her to move as he/she truly liked him/her as a friend, but liked him/her more as a lover; -He/She had performed oral sex on Resident #115 two times, once after supper and once before lunch, and both times the act took place in Resident #115's room; -Resident #115 came to his/her room and asked him/her to give him/her oral sex, so they went to Resident #115's room; -He/She had agreed to perform oral sex, but told Resident #115 he/she did not want to complete the act. Resident #115 held his/her head in place so he/she could not move and did it anyway; -His/Her guardian told him/her he/she could not be in a relationship with Resident #115 or anyone else; -This all occurred after supper and right before shift change; -The second time he/she gave Resident #115 oral sex it happened the same way, even though he/she had asked him/her not to complete the act, Resident #115 did not listen and did it anyway without his/her permission; -The second occurrence happened after the 1:30 P.M. smoke break, when staff were outside with smokers; -He/She did not want to give Resident #115 oral sex a second time, but he/she wanted to keep him/her as a friend and felt obligated to give him/her oral sex; -He/She said Resident #115 said this was their little secret and he/she should not tell anyone what they are doing. -After the second time he/she gave Resident #115 oral sex, Resident #115 was in his/her bed and Certified Nurse Aide (CNA) E walked into the room; -CNA E told them if they want to be in each other's rooms, they knew the rules and the door should be open and reminded them if it was night the light had to be turned on; -The reason he/she waited so long to talk about it, he/she did not know he/she could get into trouble. He/She did not want to get Resident #115 into trouble; -He/She told the DON he/she wanted to be tested for STDs; -He/She did not have any physical injuries, but has had a flash back and woke up the night before sweating. He/She said he/she was dreaming and when he/she woke up he/she felt worthless. Review of the resident's written statements for the facility, dated 4/21/24, showed the following: -The resident had sexual relations with Resident #115; -Resident #115 forced him/herself on him/her by making the resident give him/her oral sex; -Both residents were caught by CNA E; -The resident told the Administrator about the incidents which happened in late January early February; -The resident told the Administrator he was worried about getting AIDS. During an interview on 4/26/24 at 11:09 A.M., CNA E said the following: -The day Residents #47 and #115 were caught sitting on Resident #115's bed, the door was closed and when he/she opened the door he/she found the two residents sitting on Resident #115's bed, staring into each other's eyes and he/she reminded them to keep things in the friend zone; -He/She left her job around 3/15/24 and management had a meeting with Resident #47 and #115's guardian and there was no consent obtained at that time for a physical relationship. During an interview on 4/24/24 at 1:33 P.M., the resident's Caseworker D said the following: -The facility had reported Resident #47 had been forced to perform oral sex on another resident back in January; -He/She did not feel the resident had the mental capacity to be in a relationship. During an interview on 4/30/24 at 2:41 P.M., the resident's legal guardian C said the following: -He/She was not aware the resident and Resident #115 had been in a relationship; -In order for him/her to consent for the resident to be in a relationship, he/she would have needed to have had a conversation with the facility on an as needed basis when these issues arise. Review of the resident's Capacity to Consent to Sexual Activity Form, dated 4/22/24, showed the following: -The resident could not say what level of sexual intimacy he/she would be comfortable with; -The resident did not have the capacity to say no to uninvited sexual contact; -The resident could not describe how he/she would react when the relationship ended; -The resident had been assessed, for the purpose of determining whether he/she is capable of understanding the purpose, nature, risks, benefits, and alternatives (including nonparticipation) in giving consent, making a decision about participation, and understanding that the decision about participation in the sexual activity, otherwise entitled: Capacity to Consent to Sexual Activity; -On the basis of this examination the evaluator arrived at the conclusion that this participant clearly lacks this capacity at this time; -The resident signed the document along with the evaluator, the ADON and the Social Services Director (SSD). 2. Review of Resident #115's PASARR II, dated 11/15/23, showed the following: -Diagnoses included oppositional defiant disorder (a type of behavior disorder. It is mostly diagnosed in childhood in which individuals show a pattern of uncooperative, defiant, and hostile behavior toward peers, parents, teachers, and other authority figures), attention-deficit hyperactivity disorder (ADHD) (neurodevelopmental disorders usually first diagnosed in childhood and often lasts into adulthood in which individuals have trouble paying attention or controlling impulsive behaviors (may act without thinking about what the result will be or be overly active), borderline intellectual functioning (a group of people who function on the border between normal intellectual functioning and intellectual disability), bipolar disorder, autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), moderate intellectual disabilities, intellectual disability moderate to severe (Individuals with moderate intellectual disability possess basic communication skills and can maintain self-care, often with some degree of support. Those with a severe intellectual disability exhibit considerable developmental delays), pervasive developmental disorder (characterized by delays in the development of social and communication skills), learning disorder, developmental disorder of scholastic skills (include dyscalculia (difficulty learning arithmetic) but also dyslexia (a condition of neurodevelopmental origin that mainly affects the ease with which a person reads, writes, and spells, typically recognized as a specific learning disorder in children), mood disorder, Post Traumatic Stress Disorder (PTSD) (a real disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), disruptive mood dysregulation disorder (condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts), and impulse control disorder with recurrent self-harm; -He/She needs nursing facility placement due to behavioral difficulties and/or mental illness symptoms requiring 24 hour monitoring/management; -His/Her individual limitations include intellectually disability, poor insight/judgment, and limited interpersonal support system; -His/Her individual strengths include guardianship in place and he/she is able to make his/her wants/needs known; -He/She needs a structured environment in order to assess and plan for the level of supervision required to prevent harm to his/herself or to others; -He/She requires ongoing assessment of mood, thought process and behaviors for early recognition of changes to promote early intervention and proactive modifications to plan of care. Review of the facility's guardian limitations report dated 12/22/23, showed the resident was to follow covenant guidelines. Review of the resident's care plan, dated 2/03/24 and revised 2/20/24, 4/23/24 and 4/24/24, showed the following: -Problem: The resident has a history with extensive psychiatric history, including oppositional defiant disorder, ADHD, bipolar disorder, depression, anxiety, suicidal ideation with attempts of self-harm, moderate to severe intellectual disabilities including autism (varying with hospitalizations and placements), PTSD, with symptoms including anxiety, labile mood, hopelessness, worthlessness, loss of appetite, fearfulness, aggressive and assaultive behavior, paranoia, perseveration, defiance, poor concentration, lack of insight and poor judgement (dated 2/03/24); -Problem: The resident has manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. These behaviors include hypersexuality, seeking sexual relationship from peers (dated 2/20/24); -Intervention: He/She continues to be advised to refrain from physical contact intimacy. Discussed alternatives including masturbating privately and seeking assist to procure device to aid in such if desired. Review of the resident's progress notes, dated 2/11/24, showed the resident was noted to hold hands and be flirtatious with a peer. Resident educated on proper friendly boundaries and not having guardian permission for relationships. Resident acknowledged understanding and states will be friends until guardian approves otherwise with no signs or symptoms or pressure or distress from peer. Review of the resident's admission MDS, completed by facility staff, dated 2/14/24, showed the resident had moderately impaired cognition. Review of the facility clinical census, dated 3/17/24, showed the resident was moved to another hall. Review of the resident's progress notes dated 4/01/24 at 1:04 A.M., showed the resident attended 7:30 P.M. supervised smoke break and when finished he/she went to common area to sit at a table with peer (Resident #19). The resident got up from the table a couple of minutes later, and approached the peer at the same table. The resident leaned over and kissed the peer on the lips. Staff immediately intervened and educated resident on facility guidelines of no physical contact with other peers. DON, Administrator. and guardian notified. Review of the resident's progress notes dated 4/06/24 at 4:11 A.M., showed the resident became upset when redirected from peer, and became belligerent. Staff counseled the resident on guidelines and the resident walked away. The resident then friended a new peer. Was seen chatting and following new peer. Review of the resident's facility acquired written statement dated 4/21/24, showed the following: -He/She and Resident #47 were having sex, kissing, making out and were caught by CNA E in his/her bed together; -He/She and Resident #47 engaged in oral sex and kissed behind the building; -The sexual acts were done out of love; -He/She has a new boy/girlfriend and Resident #47 was jealous and has been trying to cause problems with his/her new relationship. During an interview on 4/24/24 at 12:15 P.M. and 4/25/24 at 11:38 A.M. and 12:14 P.M., the resident said the following: -He/She was not currently in a physical relationship, but he/she was in an emotional relationship with Resident #19; -He/She used to be boy/girlfriend with Resident #47; -He/She did not force Resident #47 to have oral sex, it was consensual and happened many times in each of their rooms; -He/She had oral sex with Resident #47 about two to three months ago; -He/She did not have permission from his/her guardian to have a relationship with anyone; -He/She started a relationship with Resident #19 about one month ago and had oral sex, but now cannot do anything until guardians give them permission. Review of the Resident's Capacity to Consent to Sexual Activity Form, dated 4/22/24, showed the following: -The resident was not aware of who was initiating sexual contact; -The resident could not state what level of sexual intimacy he/she would be comfortable with; -The residents' behavior was not consistent with formerly held beliefs/values; -The resident could not describe how he/she would react when the relationship ended; -The resident had been assessed, for the purpose of determining whether he/she is capable of understanding the purpose, nature, risks, benefits, and alternatives (including nonparticipation) in giving consent, making a decision about participation, and understanding that the decision about participation in the sexual activity, otherwise entitled: Capacity to Consent to Sexual Activity; -On the basis of this examination, the evaluator arrived at the conclusion that this participant clearly lacks this capacity at this time; -The resident signed the document along with the evaluator, the ADON and the SSD. During an interview on 4/24/24 at 1:43 P.M., the resident's legal guardian A said the following: -He/She was not aware Resident #115 was in a physical relationship; -He/She did not think the resident understood what it meant to be in a healthy relationship as he/she does not believe the resident ever witnessed a healthy relationship; -The issue with giving permission for a relationship never came up for Resident #115. 3. Review of Resident #19's PASARR Level II dated 9/07/18 showed the following: -Diagnoses included: Mood disorder, impulse control disorder, schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions which include delusions (false beliefs), hallucinations (seeing or hearing things that don't exist), unusual physical behavior, and disorganized thinking and speech.), PTSD, adjustment disorder, ADHD, major depressive disorder (when an individual has a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, agitation, sleep disturbances, or suicidal thoughts.) (MDD), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), bipolar disorder, borderline personality disorder, developmental delay, history of traumatic brain injury (a sudden injury that causes damage to the brain); -Historical symptoms or behaviors included seeing a psychiatrist around the age of seventeen due to depression, auditory and visual hallucinations following the death of his/her adopted father. He/She was hospitalized around the age of twenty due to suicidal ideation. He/She has attempted suicide several times in the past. He/She has self-mutilating behaviors with numerous scars on lower legs where he/she cut, burned, scratched, or otherwise hurt him/herself. He/She has chronic suicidal ideation's as he/she hears voices telling him/her to kill him/herself, paranoid thoughts, and elopement from facility; -He/She has had numerous hospitalizations for depression and suicidal ideations; -He/She requires secured/behavioral unit; -His/Her thought process/cognitive status included poor concentration, poor judgement, tangential (a communication disorder in which the train of thought of the speaker wanders and shows a lack of focus, never returning to the initial topic of the conversation), disorganized, short term memory deficit, and poor insight; -His/Her manner was cooperative and childlike; -He/She requires a nursing facility due to ongoing for safety, medication, medical and psychiatric monitoring and requires ongoing medical management and review of medications; -He/She does not make good or safe decisions. Review of the resident's care plan, initiated 5/23/22 and revised on 4/29/23, showed the following: -Problem: PASRR showed the resident had a history of behavioral challenges that require protective oversight in a secure setting. He/She began experiencing hallucinations at seventeen after the death of his/her adopted father. He/She experienced auditory and visual command hallucinations as well as suicidal and homicidal ideation. He/She has a history of suicide attempts. He/She also practiced self-mutilation by cutting self, leaving numerous scars. He/She has a diagnoses of schizoaffective and mood disorder, anxiety, major depression, and psychosis (dated 5/23/22); -Problem: The resident has a history of PTSD. PTSD affects the resident symptoms and may flare up without any known trigger. Alterations in reactivity from the traumatic event, including aggressiveness, and self-destructive behavior. Intrusion or persistently re-experienced stressors in at least one of the following ways: recurrent memories, traumatic nightmares, flashbacks, prolonged distress following traumatic reminders, significant physical symptoms after exposure to stressors. The resident states he/she was bullied in school, physically and emotionally. Triggers include loud noises, accusing him/her of doing things and unwanted touching (dated 4/29/23). Review of the facility's guardian limitations report, dated 12/22/23, showed the following: -The resident must follow covenant guidelines; -The resident may not have any relation with opposite sex peers. Review of the resident's quarterly MDS, completed by facility staff, dated 3/03/24, showed the resident was cognitively intact. Review of the resident's progress notes, dated 4/01/24 at 1:20 A.M., showed the following: -Resident attended 7:30 P.M. supervised smoke break, and when finished, went to common area and sat at a table with peer. A couple of minutes later, the peer (Resident #115) got up from table and kissed this resident. Staff immediately intervened and educated resident on facility guidelines of no physical contact with other peers. DON and Administrator notified. Left message on voicemail for guardian. Review of the resident's guardian email, dated 4/03/24 at 9:16 A.M. and 4/03/24 at 12:48 P.M., showed the following: -The email was sent to the SSD; -The guardian would like to make the facility aware of this guardian directive. The resident is not to be in a relationship with anyone (male or female). Relationships always cause him/her to become confused and when they end he/she becomes suicidal. The resident can have friends, but no romantic relationships. There should be no public display of affection between the resident and another resident. Review of the resident's progress notes, dated 4/06/24 at 5:34 A.M., showed the resident became upset at staff for redirecting him/her away from another peer. Resident became verbally aggressive, but was easily redirected. During an interview on 4/24/24 at 11:31 A.M., 4/24/24 at 4:08 P.M. and 4/25/24 at 11:46 A.M. and 12:16 P.M., the resident said the following: -He/She had consensual oral sex in Resident #115's room about one and a half weeks ago; -He/She can only be with Resident #115 in the dining room and on smoke breaks; -He /She can kiss and hold hands with Resident #115; -He/She just wanted to do a favor for Resident #115, because he/she said he/she was horny. Review of the resident's Capacity to Consent to Sexual Activity Form, dated 4/22/24, showed the following: -The resident's behavior was not consistent with formerly held beliefs/values; -The resident did not realize that the relationship may be time limited due to placement of male/female on unit was temporary; -The resident could not describe how he/she would react when the relationship ended; -The resident had been assessed, for the purpose of determining whether he/she is capable of understanding the purpose, nature, risks, benefits, and alternatives (including nonparticipation) in giving consent, making a decision about participation, and understanding that the decision about participation in the sexual activity, otherwise entitled: Capacity to Consent to Sexual Activity; -On the basis of this examination the evaluator arrived at the conclusion that there was doubt about this participant's capacity at this time and further evaluation was necessary; -The resident signed the document along with the evaluator, the ADON and the SSD. Observation on 4/24/24 at 4:02 P.M. showed Resident #115 knocked on the resident's door while the surveyor interviewed the resident. Resident #115 was not supposed to be allowed on the hall as he/she did not live on the hall. During an interview on 4/24/24 at 1:57 P.M. and 5/01/24 at 12:21 P.M., the resident's legal guardian B said the following: -He/She did not want Resident #19 to have any relationships; -He/She felt the resident did not have the capacity to consent to a relationship of any kind; -There had been times in the past when Resident #19 has been in a relationship and when it ended he/she was taken to the hospital for suicidal ideations; -He/She felt the resident could not handle any breakup without it causing suicidal ideations; -He/She emailed a directive to the facility on 4/03/24 stating the resident could not have a boy/girlfriend relationships; -The resident does not know what a relationship was because he/she has never been in a loving relationship; -The resident can be easily taken advantage of by anyone dealing with anything, for example, there were other residents who were trying to get his/her coloring books and pencils and a fight would ensue; -When he/she spoke with the resident on the phone he/she had told him/her that he/she had a boy/girlfriend and he/she told him he/she did not agree and that he/she knew what could happen if/when the relationship ended; -He/She sent the email on 4/03/24, because the resident told him/her he/she was in love with another resident; -His/Her family member called after speaking with the resident to report he/she was afraid the resident was going away with Resident #115 to another family 's home in another city; -He/She then contacted the resident and told him/her he/she could not have a relationship with anyone; -He/She felt romantic relationships could cause the resident to harm him/herself as the resident does not handle his/her feelings very well when relationships come to an end; -He/Sh

Based on interview and record review, the facility failed to ensure one resident (Resident #13) with a mental health disorder, in a review of 13 sampled residents, received individualized treatment and services to meet his/her psychosocial needs. The resident had a history of alcohol use, impulsiveness, self-mutilation, and multiple suicide attempts. On 8/3/23, the resident cut himself/herself and swallowed batteries. Staff believed the resident's behavior was a result of staff confiscating contraband (chewing tobacco and cigarettes) after the resident returned to the facility after attending church. On 11/5/23, staff reported the resident was upset when staff confiscated chewing tobacco, cigarettes and two bottles of alcohol-based hand sanitizer upon the resident's return from attending church. The resident also presented with signs/symptoms of alcohol consumption. On 11/12/23 and 11/13/23, the resident refused his/her medications and reported to staff he/she was upset about not having hand sanitizer. On 11/19/23, the resident was restricted from going to church and cut his/her forearms multiple times with a razor blade, requiring sutures. The resident denied this was a suicide attempt, however, reported he/she cut himself/herself because he/she was not allowed to go to church. The facility failed to develop and implement meaningful behavioral health interventions specific to the resident to address the resident's alcohol use, impulsiveness, and self-mutilation to prevent episodes of self-injurious behavior and harm. The facility census was 111. Review of the facility's Behavioral Emergency Policy, last revised on 1/5/23, showed the following: -If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident to resident altercations the following steps will occur: 1. The licensed nursing staff/team leader/Resident Care Coordinator (RCC)/nursing administration will assess the resident who is exhibiting such behaviors, ensuring that safety of the resident and others is the first priority. A one-to-one monitoring of the resident will be initiated immediately; 2. The Director of Nurses or Designee and the Administrator or Designee and Regional Director will be notified regarding assessment findings. The Director of Operations or Chief Operating Officer will review the resident ' s plan of care with the Regional Director and Administrator/Designee and will determine if the resident ' s needs can continue to be met safely or whether the resident continues to be appropriate for placement at the facility. The licensed nurse/Team Leader/RCC will follow direction from the Management Team Member on call, Resident Care Coordinator and the Administrator or Designee; 3. The guardian will be notified at this time and imposed limitations may be placed on the resident, including hospitalization or other specific directives; 4. The physician will be notified of the licensed nurse/Team Leader/RCC assessment and orders will be followed; 5. If the Management Team Member on call and Administrator or Designee decide that the resident ' s needs cannot continue to be safely met, or that the resident is not appropriate for placement at the facility, the physician will be notified by the licensed nurse requesting for a psychiatric evaluation at this time an immediate discharge notice may be sent with the resident. 6. The Administrator/DON/designee will complete an Administrative Investigation within 24 hours of the behavioral emergency. This may include a PRN (as needed) Interventions Form and notification of state agencies in the event that criteria are met. 7. The Licensed Nurse will document the behavioral emergency in the medical record by utilizing the BIRPEEEE documentation guidelines: a. B=Behavior Emergency-define behavior; b. I =Intervention-document interventions, note behavior emergency policy and document interventions from the behavioral emergency policy; c. R = Reaction/Response - Document reaction and response of resident after interventions; d. P=Plan-Continue current plan of care, continue observation/monitoring of resident; e. E = Evaluation; f. E = Evaluation; g. E = Evaluation; h. E = Evaluation; 8. Documentation of the Behavior Emergency in the Administrative Investigation will include evaluation of the resident's behavior, including consideration for precipitating events or environmental triggers, and other related factors in the medical record with enough specific detail of the actual situation to permit underlying cause identification to the extent possible, not identifying or attempting to identify the root causes of the behaviors and not revising the plan of care with measurable goals and interventions to address the care and treatment for a resident with behavioral and/or mental/psychosocial symptoms. 1. Review of Resident #13's Preadmission Screening and Resident Review (PASRR) Evaluation (a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in a nursing facility regardless of the source of payment. The screening assures appropriate placement of persons known or suspected of having a mental impairment and also that the individual needs of mentally impaired persons can be, and are, being met in the appropriate placement environment), completed 11/19/09, showed the following: -Diagnoses included schizoaffective disorder, bipolar disorder (brain disorder that causes changes in a person's mood, energy, and ability to function), borderline personality disorder (characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships), and anxiety; -History of self-mutilation, multiple suicide attempts, impaired interpersonal and social functioning, and impulsiveness; -Binge drinks when in the community; -Avoids interpersonal relationships and is socially isolated; -Recommend that client be in a safe, secure environment and have support for emotional issues, provided with an opportunity for increased interaction via small groups. Would benefit from counseling for grief-loss adjustment. Also needs monitoring for safety due to smoking in areas not designated, impulsive behavior, self-mutilation, and multiple suicidal attempts. (Review of the resident's medical record showed no documentation of a more current PASRR.) Review of the resident's face sheet, showed the following: -The resident's original admitted was 1/13/10; -The resident was his/her own responsible party; -Diagnoses included major depressive disorder (mood disorder that interferes with daily life), bipolar disorder, borderline personality disorder, schizophrenia, and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/3/23, showed the following: -Cognitively intact; -No behaviors directed toward self or others; -Independent with ambulation. Review of the resident's care plan, last updated 7/27/23, showed the following: -Problem: Coping; -Determine the resident's coping methods. Coping skills included music, outside time, smoking, religion/church, and watching the news. -Encourage participation in self-calming behaviors such as breathing exercises, meditation or guided imagery; -Encourage times of rest and relaxation between care activities; -Provide reassurance to resident. -Problem: The resident had a long history of mental illness; -He/She enjoyed attending local church and regularly went with a staff member; -He/She wished to attend the following spiritual activities: church service (in the town where the facility was located). -He/She will attend church as he/she feels like. -Problem: Risk for harm self-directed or other directed behavior potentially causing harm, mood disorders, psychotic disorder. The resident has exhibited self-harm behavior related to not receiving monies from his/her family member's passing (11/2022); -Hourly face checks; -Encourage the resident to verbalize cause for aggression; -Monitor for cognitive, emotional or environmental factors that may contribute to violent behaviors; -Monitor for signs/symptoms of agitation; -Offer acceptable alternatives to unacceptable situation; -The resident will be placed on intensive monitoring when necessary; -Utilize diversion techniques as needed. -Problem: The resident has a long history of mental illness and frequent psychiatric hospital admissions. The resident's current diagnoses are schizoaffective disorder, bipolar disorder, borderline personality disorder and anxiety. The resident has a history of self-mutilation, multiple suicide attempts and impulsiveness; -Behavior modification programs as needed; -Interdisciplinary team and guardian (the resident did not have a guardian) involvement as necessary; -Long-term psych management and counseling if needed; -One-on-one interventions as needed; -Pharmaceutical interventions as needed; -The resident enjoys attending a local parish church and regularly goes with a staff member. Review of the resident's incident note, dated 8/3/23 at 8:52 P.M., showed the following: -The resident came back from church with numerous items, chew, cigarettes on his/her person; -He/She came up to the staff at approximately 6:00 P.M. stating he/she cut himself/herself and swallowed batteries; -The staff sent the resident to emergency department via ambulance. Review of the resident's Registered Nurse (RN) Investigation, dated 8/3/23, showed the following: -On 8/3/23, the resident reported he/she swallowed batteries and cut himself/herself. The resident had superficial cuts on his/her arm. Orders received to send to the hospital; -The resident attended church earlier in the day and returned with chewing tobacco and cigarettes. The items were secured at the nurses station and the resident was advised he/she could use those items in accordance with facility safety and smoking policies. The resident was unable to identify the utensil used to cut himself/herself saying, I don't know. It's not deep. No sharp objects were found including but not limited to razors, CDs, glass or cans. During an interview on 12/4/23 at 1:15 P.M., the Director of Nursing (DON) said the following: -On 8/3/23, the resident walked up to the nurses station and said he/she swallowed batteries because he/she wanted to; -She thought the resident swallowed the batteries because the staff took the contraband away from the resident upon returning to the facility; -The resident used a piece of the surgical masks to cut himself/herself; -The staff were educated not to leave surgical masks or N95 masks in the trash cans the residents have access to unsupervised. Review of the resident's medical record showed no evidence staff identified the root cause for the resident's self-harm or resident-specific interventions to address the incident and to prevent future incidents of self-harm, including cutting. Review of the resident's admission note, dated 8/17/23, showed the following: -Screening: Does the resident currently or have a history of a substance use or been diagnosed with substance use disorder: Yes. Substance of choice: alcohol. Frequency of use: Daily. -Education/Notification : Safety concerns - recent suicidal ideology. Review of the resident's progress notes, dated 8/20/23 (Sunday), showed the day shift reported the resident was verbally aggressive towards staff but was easily redirected. No behavioral issues noted this shift. (Review showed no evidence staff attempted to identify the root cause of the resident's verbal aggression on 8/20/23.) Review of the resident's care plan, updated on 8/23/23, showed the following: -The resident has a psychosocial well-being problem related to inability to meet role expectations and ineffective coping skills. The resident has self-harming behaviors such as cutting and recently swallowed batteries; -Consult with pastoral care, social services and psych services; -Encourage participation in activities and outings; -Provide activities calendar; -Increase communication between resident/family/caregivers about care and living environment. Explain all procedures and treatments, medication, results of labs/tests, condition, all changes, rules, options; -Monitor/document resident's usual response to problems: Internal - how individual makes own changes, External - expects others to control problems or leave to fate or luck; -When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. (Review of the resident's care plan showed no specific interventions identified to address the resident cutting himself/herself or swallowing batteries.) Review of the resident's mental status exam, dated 9/15/23, showed the following: -The resident was seen for follow up visit for medication management. The resident was recently in the hospital for depression. The resident reports his/her mood is all right; -Staff report no behavioral issues; -Resident denies self-harm. Nurses notes reports when resident gets upset, he/she refuses his/her human immunodeficiency virus (HIV; an infection that attacks the body's immune system) medications (3/16/23); -Symptoms of illness included conscious desire to inflict self-harming behaviors. Reports he/she will kill himself/herself when he/she doesn't get his/her own way by refusing to take his/her HIV medications; -Assessment: Education and support provided. Zyprexa (an antipsychotic medication) and Seroquel (an antipsychotic medication) have helped manage psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). Monitor mood, behavior and side effects of medications. Review of the resident's nurse note, dated 9/24/23 at 3:43 P.M., showed the following: -The resident returned from church and agreed to contraband check; -The staff found three cans of chew hidden behind belt in waistband; -The resident gave the staff the contraband without outbursts or behaviors; -The staff smelled alcohol on the resident's breath without signs or symptoms of distress. Review of the resident's care plan showed no documentation staff addressed the resident's alcohol use. Review of the resident's annual MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She was independent with all activities of daily living; -No behaviors directed toward self or others. Review of the resident's progress note, dated 10/8/23 at 2:01 P.M., showed the following: -The resident returned to the facility at 12:24 P.M.; -His/Her eyes were red, speech slurred, drowsy affect, and odor of alcohol; -He/She denied drinking alcohol, but admitted to going to the liquor store; -The nurse advised the resident of line-of-sight requirement for protective oversight; -The resident declined to remain in common area, so one-on-one supervision initiated; -The resident said he/she would like to nap, so the staff monitored the resident every 15 minutes for eight hours for safety. Review of the resident's care plan showed no documentation staff addressed the resident's alcohol use. Review of the resident's nurse note, dated 10/22/23 at 12:45 P.M., showed the resident returned to the facility and agreed to personal search. The staff found multiple cans of chew and multiple packs of cigarettes on the resident's person and hidden chew in beltline and pocket. Review of the resident's mental status exam, dated 10/28/23, showed the following: -The resident was seen today for a follow up visit for chart review, interval history and medication management. The resident reports, I'm all right. I'm getting an iPad.; -Assessment: Education and support provided. The resident instructed if he/she feels suicidal to notify staff. Continue facility supportive plan of care and current medications. Continue to monitor mood, behavior and side effects of medications. Review of the resident's October 2023 Medication Administration Record (MAR) and progress notes showed no evidence the resident refused to take his/her medications, including his/her HIV medications. Review of the resident's behavior note, dated 11/5/23 at 1:33 P.M., showed the following: -The resident returned to the facility and agreed to personal search for contraband; -The Director of Nursing (DON) and certified nurse aide (CNA) checked the resident finding multiple cans of chew tucked in his/her beltline attempting to hide cigarettes, the lighter the staff sent him/her, and two bottles of alcohol-based hand sanitizer; -The resident had signs and symptoms of alcohol consumption by alcohol on breath, sweaty, lethargic, and very tired appearance; -The resident said he/she did not consume any alcohol while on leave of absence. During an interview on 12/1/23 at 8:59 A.M., the Assistant Director of Nursing (ADON) said the following: -The staff searched the resident for contraband upon his/her return to the facility on [DATE]; -The staff found contraband items and took the items from the resident to put in a secure area; -The resident yelled at him/her (ADON) when she confiscated hand sanitizer from the resident which was an unusual behavior for the resident. The staff felt threatened with the resident's behavior. During an interview on 12/12/23 at 2:05 P.M., the Administrator said the following: -The resident brought hand sanitizer into the building and admitted to drinking it on the way back to the facility from church on 11/5/23; -The resident had an increase in behaviors towards others following 11/5/23 when the resident returned to the facility with the smell of alcohol and had the bottles of hand sanitizer taken away from him/her. Review of the resident's progress notes, dated 11/12/23 (Sunday) at 3:45 P.M., showed the resident refused his/her noon medications. The staff educated the resident on importance of taking medications as prescribed. The resident verbalized understanding, but continued to refuse. Review of the resident's Medication Administration Record (MAR), dated 11/12/23, showed the resident refused the following medications scheduled for the noon medication pass: -Clonazepam (a sedative used to treat anxiety and panic disorder) 0.5 milligrams (mg), give one tablet three times a day related to bipolar disorder; -Hydroxyzine HCL (an antihistamine used to treat anxiety) 25 mg, give one tablet three times a day related to anxiety disorder. Review of the resident's progress notes, dated 11/12/23 at 6:18 P.M., showed the following: -The resident was not compliant with medications; -The staff attempted to redirect and educate the resident on the importance of staying medication compliant. The resident did not take medication. The medication was destroyed, and the staff notified administration. Review of the resident's MAR, dated 11/12/23, showed the resident refused the following medications scheduled for the evening medication pass: -Benztropine mesylate (an anti-tremor medication) 0.5 mg, give one tablet in the evening related to dysthymic disorder (mild, but long-lasting form of depression); -Prazosin HCL (an antihypertensive medication also used to manage/treat nightmares) 2 mg, give one capsule at bedtime related to nightmare disorder (sleep disorder characterized by recurrent nightmares that cause significant distress); -Quetiapine fumarate (an antipsychotic medication) 200 mg, give two tablets in the evening related to schizophrenia; -Trazodone HCL (an antidepressant medication) 100 mg, give one tablet in the evening related to insomnia (sleep disorder in which you have trouble falling and/or staying asleep); -Olanzapine (an antipsychotic medication) 5 mg, give one tablet two times a day related to schizophrenia; -Clonazepam 0.5 mg, give one tablet three times a day related to bipolar disorder; -Hydroxyzine HCL 25 mg, give one tablet three times a day related to anxiety disorder. Review of the resident's medical record showed no documentation the facility identified the root cause for the resident to refuse his/her medications on 11/12/23 (Sunday) or interventions implemented to address the root cause. Review of the resident's MAR, dated 11/13/23, showed the resident refused the following medications during the morning medication pass: -Fluoxetine HCL (an antidepressant medication) 20 mg, give two tablets in the morning related to major depressive disorder; -Triumeq (antiviral combination) 600-50-300 mg, give one tablet one time a day for HIV; -Olanzapine 5 mg, give one tablet two times a day related to schizophrenia (second missed dose); -Clonazepam 0.5 mg, give one tablet by mouth three times a day related to bipolar disorder (third missed dose); -Hydroxyzine HCL 25 mg, give one tablet by mouth three times a day related to anxiety disorder (third missed dose). Review of the resident's progress notes, dated 11/13/23 at 11:28 A.M., showed the following: -The resident refused all morning medication and stated he/she did not want them. (The resident's morning medications included the medication to treat HIV); -The staff notified the Administrator, DON, ADON, and resident care coordinator (RCC); -The resident was self-guardian, so staff educated the resident on health factors of refusing medication. Review of the resident's MAR, dated 11/13/23, showed the following for the noon medication pass: -The resident did not receive his/her scheduled morning medication; -The resident refused clonazepam 0.5 mg (fourth missed dose) and hydroxyzine HCL 25 mg (fourth missed dose). Review of the resident's progress notes, dated 11/13/23 at 1:05 P.M., showed the resident continued to refuse all medications. (The resident did not receive his/her medication to treat HIV.) Review of the resident's MAR, dated 11/13/23 showed the resident did not receive his/her morning or afternoon medications (including his/her medication to treat HIV) and refused the following medications during the evening medication pass:-Benztropine mesylate 0.5 mg, give one tablet in the evening related to dysthymic disorder; -Prazosin HCL 2 mg, give one capsule at bedtime related to nightmare disorder; -Quetiapine fumarate 200 mg, give two tablets in the evening related to schizophrenia; -Trazodone HCL 100 mg, give one tablet in the evening related to insomnia; -Olanzapine 5 mg, give one tablet two times a day related to schizophrenia; -Clonazepam 0.5 mg, give one tablet three times a day related to bipolar disorder; -Hydroxyzine HCL 25 mg, give one tablet three times a day related to anxiety disorder. Review of the resident's progress notes, dated 11/13/23 at 9:07 P.M., showed the following: -The resident refused bedtime medications; -The certified medication technician (CMT) spoke with the resident and was able to convince the resident to take the medications; -The resident said he/she was upset about not having hand sanitizer. Review of the resident's November 2023 MAR showed no documentation the resident received any of his/her scheduled medications on 11/13/23 Review of the resident's medical record showed no documentation of interventions implemented to address the root cause of the resident's refusal to take his/her medications, including not having hand sanitizer. Review of the resident's progress notes, dated 11/19/23 at 10:29 A.M., showed the following: -The resident's peers found the resident in his/her room bleeding profusely from his/her arms and upper left hand; -The resident said the behavior was in response to not being able to attend church services this day due to inappropriate behavior during a previous outing. (No specific documentation in the note to identify the inappropriate behavior from previous outing); -The staff found two thin razor blades on the resident's person. Review of the resident's RN Investigation, dated 11/19/23, showed the following: -On 11/19/23, the resident was noted to have blood coming from both of his/her outer forearms. The right forearm with two 1-inch long lacerations; the left forearm with three 1-inch long lacerations; and left hand with two 2-inch lacerations. The resident said he/she did this because he/she wasn't allowed to go to church today. When asked what he/she used to cut himself/herself, the resident said nothing. Small metal pieces were noted on the bedside table; -The resident was sent to the emergency department for evaluation and treatment with sutures needed. Review of the emergency department nurse documentation, dated 11/19/23, showed the following: -Emergency medical services (EMS) state the resident cut both forearms at the health care center where he/she lives. He/She has attempted this in the past. -Facility staff states the resident said he/she cut his/her forearms because he/she was not allowed to go to church because of bad behavior. Also reports he/she likes to drink hand sanitizer. Review of the emergency department physician documentation, dated 11/19/23, showed the following: -The resident was brought from care facility after cutting himself/herself because he/she was upset because they would not allow him/her to go to church. The resident said he/she did not try to kill himself/herself although he/she did say he/she wanted to hurt himself/herself at the facility, but denies it was a suicidal attempt and denies current suicidal ideations; -The resident has cut himself/herself before and has a history of depression. The resident's symptoms currently are mild in nature; -Laceration #1: right anterior distal forearm. Length: 3.5 centimeters (cm). Sutures: Five subcutaneous sutures (suture placed immediately below the top layer of the skin); -Laceration #2: left anterior distal forearm. Length: 2.5 cm. Sutures: Five subcutaneous sutures; -Laceration #3: left distal anterior forearm. Length: 3 cm. Sutures: Seven subcutaneous sutures; -Laceration #4: left distal anterior forearm. Length: 3 cm. Sutures: Five subcutaneous sutures; -Laceration #5: left distal anterior forearm. Length: 2 cm. Sutures: Two subcutaneous sutures. During interviews on 12/1/23 at 9:42 A.M. and 12/4/23 at 9:00 A.M., the resident said the following: -On 11/19/23, the staff did not allow him/her to go to church and it made him/her feel depressed. He/She was upset and cut himself/herself with a razor. He/She was not trying to commit suicide; -He/She got the shaving razor out of the trash can in his/her main hallway on 11/19/23 when he/she could not go to church. He/She took the razor blade out of the shaving razor to cut himself/herself; -He/She would tell the staff when he/she was upset about something, but did not tell anyone prior to cutting himself/herself on 11/19/23, because it was the staff who would not let him/her go to church. During interview on 12/4/23 at 9:08 A.M., Licensed Practical Nurse (LPN) A said he/she did not remember the interventions in place to prevent the resident from self-harm. During an interview on 12/12/23 at 10:45 A.M., Certified Medication Technician (CMT) C said the following: -He/She did not know the reason why the resident swallowed batteries on 8/3/23, but the resident was on every 15-minute checks; -Prior to 11/19/23, the staff performed more frequent face checks and 1:1 based on how grouchy the resident was at the time; -On 11/19/23, the staff implemented intense monitoring of every 10 to 15-minute checks when the resident was upset about not being allowed to go to church; -The staff documented and educated the resident when he/she refused to take medication and sent a message to the DON or department head, who would notify the physician; -The resident listened to gospel music, read the Bible, and watched television as coping mechanisms. During interviews on 12/1/23 at 8:59 A.M. and 10:55 A.M., the ADON said the following: -He/She thought the resident drank the hand sanitizer; -The staff told the resident on 11/19/23 that he/she could not go to church for his/her safety, then the resident cut himself/herself; -The resident refused to take medication when he/she became upset. Staff discussed with the resident how not taking medication was hurting him/her and not the staff; -Some interventions in place to prevent the resident from self-harm was talking with the resident, going to church, streaming service for church service, one-on-one attention, prayer with the Administrator, and speaking to a parent via phone. During interviews on 11/29/23 at 9:40 A.M., 12/5/23 at 1:15 P.M. and 12/12/23 at 1:43 P.M., the DON said the following: -The resident made threats of harming himself/herself in the past when he/she did not get his/her way. Most of the time, the resident refused to take his/her medications; -If staff told the resident, no, then the resident would refuse to take medications; -The staff reported the resident's refusal to take medication and an administration staff would discuss it with the resident; -The resident was not always on 15-minute check, however on 11/19/23, the resident was on the 15-minute checks because he/she was unable to go to church; -The face checks were not documented because the resident was not on one-on-one; -On 11/19/23, the resident used a shaving razor to cut himself/herself. The resident did not tell staff where he/she got the shaving razor; -The resident said he/she was mad about not being able to go to church; -The resident's coping skills included the implemented interventions of listening to music on a portable CD player, prayer in the morning, watching television, watching his/her tablet, and smoking; -She expected the resident's care plan to be updated with interventions to address the resident harming himself/herself on 8/3/34 and then again on 11/19/23. During an interview on 1/3/24 at 10:09 A.M., the Administrator said the following: -He did not expect the staff to implement additional measures when the resident returned with contraband on 8/3/23, because the staff had already searched the resident and the resident did not say anything to the staff taking away the contraband; -He expected staff to implement interventions to address the resident after he/she cut himself/herself and swallowed batteries on 8/3/23. He thought the interventions were implemented; -He expected the staff to identify the root cause for the resident's behavior and implement interventions to specifically address the root cause to prevent further incidents after 8/3/23. The intra-disciplinary team met with the resident to speak about the resident's actions and staff implemented one-on-one supervision for at least four hours (not documented) upon the resident's return from the hospital; -The resident was impulsive, and the staff could not have prevented the resident from harm at all times, because the resident did not voice or demonstrate any behaviors; -The resident was his/her own person and consumed alcohol outside the facility; -The ADON and members of the church offered the resident rides to church, which the resident agreed to go but would leave to walk back alone; -The Administrator and Director of Nursing disagree with the statement that the resident became very upset and yelled because it was never reported to them and they had not witnessed the resident ever yell or become upset when staff took contraband from the resident; -The resident became frustrated about being caught with contraband, but never verbally yelled; -He did not remember why the resident refused his/her medications on 11/12/23; -The resident refused to take his/her medications for various reasons, such as, if the resident had a bad phone call from the family, the resident did not receive money from a parent's death, etc.;<b [TRUNCATED

Based on observation, interview, and record review, the facility failed to ensure weights were monitored weekly after a significant weight loss was identified as directed in the facility policy, failed to provide interventions as ordered by the physician to prevent weight loss, failed to re-evaluate interventions to prevent weight loss for effectiveness, failed to monitor the meal and supplement consumption as directed in the facility policy, failed to update the resident's care plan to reflect the resident's current orders/interventions as directed in the facility policy, and failed to ensure dental needs were identified and actions taken to prevent further weight loss for one resident (Resident #21), who had a 14.5% significant weight loss, in a review of 31 sampled residents. The facility census was 108. Review of the facility's policy, Weight Loss, last revised 2/26/21, showed the following: -Maintain acceptable parameters of nutritional status, such as body weight and protein level, unless the resident's condition demonstrates that this is not possible; -The following parameters for weight loss require physician notification, legal guardian and or the resident's responsible party, the dietitian. The information and notifications will be documented in the resident's record. -Interventions shall also be documented: -5% weight loss in 30 days: will involve physician notification, possible orders for dietary supplement, dietitian may be notified; -7.5% weight loss in three months: requires physician notification, dietitian to consult, and any orders to increase dietary intake, supplements etc; -10% weight loss in six months: requires physician notification, dietitian to consult, and any orders to increase dietary intake, supplements to be increased, changed etc.; -The dietitian can be consulted at anytime. Ensure that documentation with recommendations are charted after any consultation with physician or dietitian; -Nursing staff will follow all recommendations and physician orders. Laboratory results such as serum [MEDICATION(S)] levels will be called to the primary physician and the dietitian will be notified of the results; -Residents with concerns for weight loss will be weighed as ordered by the physician and at least weekly. Weight loss issues will be addressed in the quality assurance (QA) meetings and will be added to the quality assurance and performance improvement (QAPI) report monthly. -The Assistant Director of Nurses (ADON) or designee will follow-up to ensure that weight losses meeting above parameters are followed and that the physician and dietitian are consulted; -Snack times and snack intake sheets will be filled out; -If the resident is refusing his/her meal or portions of his/her meal/snack, then alternative foods will be offered to ensure that adequate intake is provided to the resident; -QAPI meeting will address offering other food choices and different types of snacks that continue to meet the residents required nutritional diet/intake, this should be added to the resident care plan; -Accurate documentation of intakes on both meal sheets and snack sheets must be completed by the nursing staff; -If a resident triggers for a weight loss or gain, the resident will be placed on weekly weights and weights will be monitored by the Resident Care Coordinator (RCC)/ADON/Director of Nursing (DON) until stable. 1. Review of Resident #21's annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/24/17, showed the resident was edentulous (no natural teeth or tooth fragments). Review of the resident's care plan for weight loss, last revised 4/14/21, showed the following: -The resident has a current diet order for a regular diet and regular liquid; -Goal: Will continue to maintain current nutritional status; -The resident has unplanned/unexpected weight loss related to poor food intake; -The resident often falls asleep while eating; cues and reminders provided; -Goal: The resident will consume two of three meals/day; -Give the resident supplements as ordered; -Alert nurse/dietitian if not consuming on a routine basis; -If weight decline persists, contact physician and dietician immediately; -Labs as ordered. Report results to physician and ensure dietician is aware; -Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss; -Monitor and record food intake at each meal. (The resident's Care Plan did not indicate if the resident had dentures or was edentulous as identified on the MDS, dated [DATE]). Review of the resident's weight record showed the resident's weight on 7/1/21 was 177 pounds (lbs). Review of the resident's Physician's Order Sheet, dated 7/6/21, showed the resident was on a regular diet with pureed texture. Review of the resident's weight record showed the following: -On 8/5/21, staff documented the resident weighed 178 lbs and 171 lbs (both weights were recorded for this date); -On 9/7/21, the resident weighed 170.4 lbs Review of the resident's Dietitian Note, dated 9/9/21, showed the following: -The resident remains on a pureed diet; -The resident continues to eat well with 76-100% of most meals consumed; -Labs 9/2/21: Total protein (measures the total amount of two classes of proteins found in the fluid portion of your blood, low value can indicate liver, kidney disease, and/or malnutrition) 5.7 low (normal range is 6.0 to 8.3 grams per deciliter (g/dL)), [MEDICATION(S)] (a protein made by the liver, lower value may indicate malnutrition, liver disease, kidney disease, or an [CONDITION(S)] disease) 2.9 low (normal range is 3.5 to 5.5 g/dL), hemoglobin A1C (Glycated hemoglobin is a form of hemoglobin that is chemically linked to a sugar, measures your average blood sugar levels over the past 3 months) 7.9% high (target should be 7.0 - 7.5%); -Height: 68 inches; -September 2021 weight: 170 lbs; down 8 lbs in one and three months, and down 5 lbs in six months; -No recommendations at this time; -Will continue to follow and be available as needed. Review of the resident's admission MDS dated [DATE], showed the following: -Moderate cognitive impairment; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Weight 170 lbs; -Required supervision with eating; -No swallowing issues; -No significant weight loss or gain; -No oral/dental issues. (The MDS was not not marked as edentulous.) Review of the resident's Physicians Orders Sheet, dated 9/24/21, showed the resident was on a regular diet, regular texture. Review of the resident's Dietary Manager note, dated 10/25/21, showed the following: -The resident is on regular diet with super cereal (a recipe that combines different ingredients and nutrients that when combined, makes a high-calorie, nutritious, and fortified cereal, fortified is to add nutrients not normally there) at breakfast; -His/Her weight was 172 lbs; -There are no concerns at this time. Will follow up. Review of the resident's care plan, progress notes, dietician notes or physician's orders showed no documentation the resident was to receive super cereal as indicated in the dietary manager's note dated 10/25/21. Review of the resident's weight record showed the resident's weight on 10/27/21 was 161.8 lbs (a significant weight loss of 10.2 lbs/5% weight loss in one month, and 15.2 lbs/8.5% weight loss in three months). Review of the resident's medical record showed no documentation staff notified the resident's physician or the registered dietician of the resident's significant weight loss as directed by facility policy. Review showed no documentation the resident's goals or interventions to prevent weight loss were re-evaluated or revised and no new interventions to prevent weight loss were implemented. Review showed no evidence staff added weekly weights to the resident's plan of care as directed in facility policy following a weight loss. Review of the resident's weight record showed the resident's weight on 11/29/21 was 158 lbs (a weight loss of 3.8 lbs since 10/27/21). Review of the resident's Dietitian Note, dated 11/29/21, showed the following: -The resident's diet changed 9/24 from a pureed diet to a regular diet, thin/regular liquids continued; -The resident has been having a variable intake, eating 0-100% of meals per documentation; -The resident remains on [MEDICATION(S)] (antidepressant medication that can also stimulate appetite) for appetite; -Labs: 10/1/21: [MEDICATION(S)] 3.1 low; -November 2021 weight: 158 lbs., down 8 lbs in one month, a 4.8% weight loss; down 20 lbs in three months, an 11.2% weight loss; down 16 lbs in six months, a 9.2% weight loss. -No recommendations at this time; -Will continue to monitor intake, weight and labs and will be available as needed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Weight 158 lbs, significant weight loss; -No swallowing issues; -No oral/dental issues. (The MDS was not marked as edentulous). Review of the resident's weight record showed the resident's weight on 12/14/21 was 156 lbs. Review of the resident's Dietitian Note, dated 12/30/21, showed the following: -The resident remains on a regular diet, continues to have a variable food intake, eating 0-100% of meals; -The resident needs encouragement at times to eat; remains on [MEDICATION(S)] for appetite; -Labs: 12/2/21: [MEDICATION(S)] 3.3 low, ALT ([MEDICATION(S)] aminotransferase test is a blood test that checks for liver damage) 3 low (normal range is 7 to 56 U/L (units per liter), in the elderly, low ALT levels may indicate an aging liver, declining kidney function, or poor nutrition), Hgb A1c 7.0% high; -December 2021 weight: 158 lbs, no change in one month; down 12 lbs in three months, a 7.1% weight loss; down 20 lbs in six months, an 11.2% weight loss; -No recommendations at this time. Will continue to follow and be available as needed. Review of the resident's Dietary Manager note, dated 1/7/22, showed the following: -The resident is on a regular diet with super cereal for breakfast and limited starch diet; -The resident's weight is down to 158 lbs; -He/She has spoken to the resident and he/she has not been eating well at all; -He/She asked the resident if he/she could buy him/her a burger from the local diner, and the resident said, no; -Facility staff are working on getting the resident to eat again. Will follow up. Review of the resident's care plan and physician's order showed no documentation directing staff to provide the resident with super cereal and a limited starch diet as indicated in the dietary managers note, dated 1/7/22. Review of the resident's weight record showed the resident's weight on 1/12/22 was 156 lbs. Review of the resident's Dietitian Note, dated 1/14/22, showed the following: -The resident remains on a regular diet; continues to have a variable intake; continues to eat 0-100% of meals; -Nursing reports he/she isn't even snacking like he/she usually does; -The resident remains on [MEDICATION(S)] for appetite; -Labs: 1/7/22: [MEDICATION(S)] 3.3 low, Hgb A1c 7.8% high; -January 2022 wt: 156 lbs, down 2 lbs in one month; down 10 lbs in three months, a 6.0% weight loss; down 21 lbs in six months, an 11.9% weight loss; -Weight loss has slowed. No recommendations at this time; -Will continue to monitor intake, weight and labs and will be available as needed. Review of the resident's medical record showed he/she was discharged to the hospital on 2/10/22. Review of the resident's hospital lab report, dated 2/10/22, showed the resident's [MEDICATION(S)] was 2.5 low and total protein was 5.9 low (normal range is 6.0 to 8.3 grams per deciliter (g/dL) or 60 to 83 g/L). Review of the resident's Hospital Discharge Summary, dated 2/14/22, showed the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Bacterial pneumonia (infection of the lung); -Septic shock (widespread infection causing organ failure and dangerously low blood pressure); -Urinary tract infection from e.coli (bacteria found in the bowel); -Moderate malnutrition (lack of sufficient nutrients in the body); -Moderate dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake); -Acute kidney injury. Review of the medical record showed the resident returned to the facility on [DATE]. During an interview on 5/26/22 at 10:21 A.M., the Dietary Supervisor (DS) said the nursing staff sent a pink communication sheet to the dietary department on 2/14/22 for the resident's readmission. The pink slip said the resident was on a mechanical soft diet, it did not have any nutritional supplements listed. That was the last communication he/she received regarding the resident's diet. Review of the resident's weight record showed the resident's weight on 2/15/22 was 152 lbs (a weight loss of 4 lbs since 1/12/22). Review of the resident's Physician's Order Sheet, dated 2/16/22, showed orders for a regular diet, mechanical soft chopped meat texture, thin/regular consistency, house supplement two times daily, and super cereal with breakfast. Review of the resident's care plan showed no documentation staff updated the care plan with the resident's weight loss, new diet orders, or new interventions to prevent further weight loss. Review of the resident's medical record showed no documentation staff implemented weekly weights as directed by facility policy following weight loss. Review of the resident's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -New signs and symptoms [CONDITION(S)], fluctuates; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Weight 152 (10.59% wt loss since September 2021), significant weight loss, not on physician prescribed plan; -No swallowing issues; -No oral/dental issues, (not marked edentulous). -Required limited assistance with eating. Review of the resident's Dietitian Note, dated 2/22/22, showed the following: -The resident was sent out to the hospital on 2/10/22, and was readmitted on [DATE]; -The resident's diet changed on 2/16/22 from a regular diet to a mechanical soft diet with chopped meat. Thin/regular liquids remain the same; -The resident also started on super cereal with breakfast and house supplements two times daily on 2/16/22; -The resident to use built-up silverware; -The resident continues to have a variable intake, needs encouragement to eat at times; -The resident remains on [MEDICATION(S)]; -February 2022 weight: 152 lbs, down 4 lbs in one month, down 6 lbs in three months, down 26 lbs in six months, a 14.6% weight loss; -No recommendations at this time since supplements and fortified food just initiated. Will continue to follow and be available as needed. Review of the resident's weight record showed the resident's weight on 3/14/22 was 147 lbs. Review of the resident's Physician's Orders, dated 3/23/22, showed [MEDICATION(S)] (a diuretic) 40 milligrams two times daily for [CONDITION(S)] for 21 days. Review of the resident's Dietitian Note, dated 3/25/22, showed the following: -The resident remains on a mechanical soft diet with chopped meat, thin liquids, house supplement two times daily, and super cereal with breakfast; -The resident remains on [MEDICATION(S)]; -Labs: Sodium level 146 high (high sodium level can indicate dehydration), [MEDICATION(S)] 2.5 low, Hgb A1c 6.5% high; -March 2022 weight: 147 lbs., down 5 lbs in one month, a 3.3% weight loss; down 11 lbs in three months, a 7.0% weight loss; down 23 lbs in six months, a 13.5% weight loss. -Discussed resident in monthly weight meeting held yesterday; -The resident had a room move and has been doing better lately, eating better per nursing; -The resident will sometimes drink his/her nutritional supplements and sometimes will refuse them; -The resident also was started on [MEDICATION(S)] due to [CONDITION(S)] (swelling caused by excess fluid trapped in your body's tissues); -No recommendations. Will continue to monitor intake, weight and labs and will be available as needed. (Review of the resident's Physician Orders showed the [MEDICATION(S)] was started on 3/23/22 after the resident's weight of 147 on 3/14/22.) Review of the resident's meal consumption log, dated 4/17/22-4/30/22, showed staff documented two out of approximately 39 meals. (Review of the medical record showed no evidence staff documented any other meal consumption or nutritional supplement consumption as directed by facility policy.) Review of the resident's weight record showed the resident's weight on 4/21/22 was 142 lbs. Review of the resident's Dietitian Note, dated 4/25/22, showed the following: -The resident remains on a mechanical soft diet with chopped meat and thin liquids, house supplement two times daily, and super cereal with breakfast; -The resident eating 26-75% of most meals; -The resident remains on [MEDICATION(S)]; -Labs: [MEDICATION(S)] 3.1 low; -April 2022 weight: 142 lbs, down 5 lbs in one month; down 14 lbs in three months, a 9.0% weight loss; down 24 lbs in six months, a 14.5% weight loss; -No recommendations at this time. Will continue to follow and be available as needed. Review of the resident's meal consumption log, dated 5/1/22-5/17/22, showed staff documented two out of approximately 50 meals. (Review of the medical record showed no evidence staff documented any other meal consumption or nutritional supplement consumption as directed by facility policy.) Review of the resident's Physician's Order Sheet, dated May 2022, showed a regular diet, mechanical soft chopped meat texture, thin/regular consistency, house supplement two times daily, and super cereal with breakfast. Review of the resident's diet order on the dietary order list, provided by the dietary manager, dated 5/16/22, showed the resident was on a regular, mechanical soft texture diet, with super cereal at breakfast, limit starch and cold cereal. (The dietary order list did not include the nutritional supplement two times daily or chopped meat texture as ordered by the physician.) During an interview on 5/16/22, at 1:15 P.M. and 5/17/22 at 9:15 A.M., the resident said the following: -He/She had lost weight; -He/She tried to eat what he/she could, but the meat was nasty; -They grind up my meat to mush; it is supposed to be cut up small but it is mushy; -Dietary staff grind up his/her meat because the housekeeper threw away his/her dentures over a year ago, and he/she doesn't have any teeth; -He/She does not know why staff grind up his/her meatloaf, riblets, and sausage. He/She can eat those meats without dentures, and they wouldn't be mushy; -If staff want to cut up his/her meat, it would be okay, but they grind it to mush; -He/She does not like green beans, but staff always give him/her green beans; -The only snack he/she gets is at bedtime; -He/She got nutritional shakes back in the Fall when he/she was on a pureed diet, but hasn't had them since; they were good; -Until a few months ago, he/she got super cereal for breakfast, but now he/she gets cold cereal. He/She got burnt out on super cereal and wanted corn flakes or fruit loops; -No one has made a dentist appointment for him/her to get new dentures; -Staff have not asked about his/her teeth, or why he/she doesn't like the meat; -Staff just say, you need to eat. Observation on 5/16/22, at 12:10 P.M., showed the following: -The resident sat in his/her wheelchair at the dining room table; -Staff served the resident a soft beef taco, canned tomatoes, potatoes with green beans, apple cobbler, and one small glass of an orange drink; -The resident consumed his/her taco, cobbler, and half of his/her orange drink; -Staff did not serve the resident a nutritional supplement, and served the resident green beans which he/she did not like (per interview with the resident) and did not eat. During an interview on 5/16/22, at 1:30 P.M., Certified Nurse Assistant (CNA) F said he/she didn't know the resident ever had dentures; the resident was edentulous. He/She didn't know if the resident had any weight loss. He/She didn't think the resident had weight loss because the resident didn't get any nutritional supplements. Observation on 5/17/22, at 8:15 A.M. showed the following: -The resident sat in his/her wheelchair at the dining room table; -The resident's meal tray was in front of him/her; -The tray contained a serving of ground sausage, a bowl with milk remaining, a few scrambled eggs, and a small amount of purple fluid in cup; -Staff did not serve the resident super cereal or a nutritional supplement with his/her breakfast. During an interview on 5/17/22, at 8:15 A.M., the resident said, look my sausage is not cup up, it is mush. Observation on 5/17/22 at 8:15 A.M. showed the resident's sausage was ground to pieces smaller than the size of rice, almost pureed texture. The resident did not consume his/her sausage. Observation on 5/17/22, at 12:05 P.M., showed the resident received ground pulled pork for the lunch meal. Staff did not serve the resident a nutritional supplement with his/her meal. During an interview on 5/17/22, at 11:05 A.M., Licensed Practical Nurse (LPN) J said the following: -He/She was not sure if the resident was currently on weight loss monitoring; -The resident has had issues with weight loss over the last year; -The resident did not get nutritional supplements at this time. During an interview on 5/17/22, at 4:10 P.M., the Resident Care Coordinator (RCC) said the following: -He/She did not know if the resident's dentures were missing; he/she just thought the resident did not wear them; -The resident has had weight loss issues over the last year; -He/She was not sure where the resident was on weight loss or interventions. He/She had been working on the night shift, and was not able to attend the weight loss meetings; -He/She did not know if the resident was getting nutritional supplements and super cereal; -The DON and ADON have been monitoring the resident's weight loss. Observation on 5/18/22, at 7:50 A.M.-8:11 A.M., showed the following: -The resident sat at the dining room table in his/her wheelchair; -Staff served the resident scrambled eggs, ground sausage, coffee cake, corn flakes, grape juice, 2% milk, and a nutritional supplement; (Staff did not serve the resident super cereal as directed in the physician's orders and the resident's meal ticket.) -The resident held up his/her nutritional supplement and said, I love theses shakes. I haven't had them in months. During an interview on 5/19/22, at 4:10 P.M., CNA K said the following: -He/She did not think the resident was a weight loss concern; -The resident did not get any nutritional supplements or anything special (for weight loss); -There was no list of residents with weight loss, the charge nurses just verbally told the aides who needed extra help or the residents with weight loss; -He/She didn't know if the resident ever had dentures, but the resident did not have them now. During an interview on 5/19/22, at 4:25 P.M., the DON said the following: -She reviews all residents' weights monthly; -The resident had significant weight loss, and continued to lose weight, but was not losing weight as fast as before. -She reviews residents of concern weekly with the interdisciplinary team, makes recommendations or notifies the dietitian if residents have continued weight loss; -The interdisciplinary team and the dietitian monitor residents with significant weight loss/gain: 5% one month, 7.5% three months, or 10% six months; -Staff weigh residents with a significant weight loss/gain weekly; -She expected staff to give nutritional supplements and fortified foods as ordered; -Nursing staff monitor to ensure the nutritional supplements/interventions were given/completed; -She was not sure why staff did not weigh the resident weekly or why staff did not give the resident super cereal or nutritional supplements; -Dietary orders should match the physician ordered diets; -She did not know the resident had missing dentures. She just thought the resident did not wear his/her dentures. During an interview on 5/26/22, at 10: 21 A.M., the Dietary Supervisor said the following: -The resident hates his/her mechanical soft diet. The resident does not like anything but a regular diet; -The resident did not like the ground meat he/she was to receive; -She was not aware the resident's diet order was for chopped meat and not ground meat; -She did not know the resident's dentures were missing; she just thought the resident did not wear them; -The nursing staff review the residents' weights, but she was not sure how often; -She participated in the monthly review of weights, and recommendations were made then; -The resident was discussed, he/she had a lot of weight loss, but had slowed down on the amount he/she was losing; -The registered dietitian looked at residents' weights every month; -Some of the diet orders on the residents' physician's orders sheet did not match the pink communication sheets he/she received, so the dietary department did not have the same orders that were on the resident's physicians orders; -The resident did not get the nutritional supplements because it was not on the order dietary had; -He/She did not know why the resident did not get his/her super cereal. Staff were expected to send super cereal and cold cereal with the resident's breakfast meal. During an interview on 5/26/22, at 1:12 P.M., the Registered Dietitian (RD) said the following: -Chopped meat should be cut small and not ground; -She did not know the resident's meat was being ground; -She expected the facility staff to carry through with physician orders and RD recommendations for residents with weight loss; -By the facility's policy, residents who trigger for significant weight loss/gain were to be weighed weekly; -Consumption tracking is important for residents with weight loss because it helps to make meaningful recommendations; -The Dietary Supervisor was expected to audit the dietary orders comparing them to the physician's orders monthly and to clarify any discrepancies; -Staff were to give nutritional supplements and fortified foods as ordered; -The facility should contact her if any interventions to prevent weight loss were not effective or a reason cannot be carried through so another recommendation could be made. The facility had not contacted her about the resident; -Resident #21 cycles and has times he/she does better and times he/she does not do as well, so the approach changes often with him/her; -The resident triggered for significant weight loss every month since October 2021 and an over 10% weight loss in six months; -Tracking the resident's meal consumption and supplements/fortified foods helps to ensure his/her nutritional needs are being met. During an interview on 6/2/22, at 10:32 A.M., the administrator said the following: -He expected staff to follow the dietitian's recommendations and physician's orders; -If fortified foods or supplements were ordered, the resident should receive them; -If a diet order says chopped meat, the meat should be chopped and not ground; -When there were new diet orders or dietary supplement orders, he expected nursing and dietary staff to get together and make sure all their orders match; -He expected staff to weigh residents with significant weight loss weekly; -If a resident with significant weight loss continues to lose weight, then staff should meet and come up with something else to try or to figure out why the resident is still losing weight, and they should document that; -He was not aware of the resident's lost dentures.

Based on interview and record review the facility failed to provide the appropriate care and services necessary to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one resident (Resident #13), who had a history of [REDACTED]. Staff intervened and found an egg size wad of toilet paper in the resident's mouth/throat. The resident's psychiatrist was not notified of this incident and reported no notifications of other behaviors significant to the resident and his/her treatment. The psychiatrist reported she should have been contacted and the resident evaluated as an inpatient at the hospital following this incident. During this time the resident remained on 15 minute checks. On [DATE] staff reported the resident was not acting right, the resident was found in the bathroom by him/herself and reported he/she was upset, with recurrent memory of past abuse. The resident remained on 15 minutes checks even though staff reported something was not right with the resident. Staff reported the resident was last checked at 11:30 P.M. Staff found the resident at 11:50 P.M. hanging from the television bracket on the wall in his/her room with a sheet around his/her neck. The resident expired. The facility census was 110. 1. Review of the facility Nursing Monitoring of Resident Policy and Procedure, undated, showed the following: -Purpose: To ensure a system is in place for residents who require increased monitoring for behavior/psychiatric and medical issues. To monitor staffing on units with residents who require more intensive monitoring; -Procedure: Residents who require more intensive monitoring due to medical behavioral/psychiatric symptoms will be monitored on visual face checks; -Residents may require more intensive monitoring based on their medical and behavioral/psychiatric needs; -New admissions to the behavioral units will be placed on intensive monitoring one to one (with in eyesight of staff at all times) if deemed necessary by the Administrator, Director of Nursing (DON), or Program Director, the one to one monitoring can only be removed by the Administrative staff; -Residents who are showing poor impulse control including verbal/physical aggression, elopement ideations, suicidal/homicidal ideations, decompensation mentally or medically may also be placed on one-to-one or two-to-one (within eyesight of staff at all times) monitoring at the discretion of the Administrative staff; -One or two-to-one monitoring will be determined at the severity of the behavior and at the discretion of the Administrator, DON, Management Team and Physician; -Residents who require intensive monitoring of one to one will have dedicated staff at all times within eye sight. 2. Review of the facility Behavioral Emergency Policy, undated, included the following information: -Purpose: To provide safe treatment and humane care to the resident in a behavioral crisis:; -Procedure: If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident to resident altercations the following steps will occur: -The licensed nursing staff/Team Leader/RCC will assess the resident who is exhibiting such behaviors, ensuring that the safety of the resident and others is the first priority. A one-to-one monitoring of resident will be initiated at this time under the direction of the licensed nurse; -Each resident who has an increased potential for aggressive behavior toward self or others, or shows a history of harm to self or others, will have an assessment completed upon admission or prior to the use of approved supportive CALM (crisis alleviation lessons and method) take down techniques; -The DON or Administrator and Management Team Member on call will be notified regarding the assessment findings. The Management Team Member on call with input from the Administrator or Designee, will decide, given the assessment findings whether the resident's needs can continue to be met safely, and whether the resident continues to be appropriate for placement at the facility. The licensed nurse/Team Leader/Resident Care Coordinator (RCC) will follow direction from the Management Team Member on call, RCC and the Administrator or Designee; -The guardian will be notified at this time and limitations may be placed on the resident, including hospitalization or other specific directives; -The physician will be notified of assessment and orders will be followed; -If the Management Team Member on call and Administrator or Designee decide that resident's needs cannot continue to be safely met, or that the Resident is not appropriate for placement at the facility, the Physician (Primary Psychiatrist, House Psychiatrist, or Medical Director) will be notified by the licensed nurse requesting Psychiatric evaluation. At this time an immediate discharge notice may be sent with the resident. The Legal Guardian will be notified of the immediate discharge and reason for the notice; -The DON/ADON/RN/Designee will complete an RN investigation within 24 hours of the behavioral emergency. 3. Review of Resident #13's Psychiatry Evaluation dated [DATE], showed the following: -admitted : [DATE]; -Chief Complaint: suicide attempt; -History: He/she presents to the emergency room with complaints of right shoulder pain. The patient states that he/she was physically restrained a few days ago and began fighting while in restraints. The patient reportedly informed the nurse of suicidal ideation with a plan. He/she said he/she decided to jump off the balcony at the facility and staff prevented his/her actions. He/she also said he/she was sexually abused by a relative. He/she was talking about suicide attempt as jumping from the balcony; -Psychiatric Review of Symptoms: Depressed mood; -Past Psychiatric History: Suicide attempts: Overdose several times; -Plan: The patient will be put in a safe and supportive environment and behavior will be monitored. Review of the resident's Pre-Admission Screening and Resident Review/Mental Illness (PASRR/MI) Level II Evaluation, dated [DATE], showed the following: -Current Psychiatric Diagnoses: [REDACTED]. -Describe historical symptoms or behaviors indicating a psychiatric disorder and time of onset: History of sexual abuse in childhood by two male family members and an early onset of depression; Self reports issues over the past several months for symptoms of night terrors, [MEDICAL CONDITION] symptoms, anxiety, panic attacks, self aggression, crying episodes and impaired concentration. Reports [MEDICAL CONDITION] with no plan; Withdrawn and isolative at times; Impulsive with periods of confusion; Flashbacks of past trauma; -Describe current symptoms or behaviors indicating a psychiatric disorder: Records indicate behavior issues inclusive of agitation, increased anxiety, self-injury behavior, aggressive behavior, labile mood and night terrors; Impulsive and confused at times; Limited insight and poor judgment; requires one-to-one supervision for safety; isolative with minimal interactions with others; periods of agitation and anxious episodes; Episodes of restlessness; Disruptive sleep with outbursts; Per physician statement dated [DATE] not currently a danger to self, not suicidal; -Thought process/cognitive status: Poor judgment, poor concentration; -Cognitive skills/Intellectual functions: Does not make good decisions; -Manner: suspicious, guarded/evasive; -Problematic Behaviors: Attention seeking behavior, refuses medications, refuses to eat, self induced vomiting, impatient and demanding, lies purposefully; -Socialization: Withdrawn/little to no interaction with others; -The resident had been depressed lately; -The resident had crying spells lately; -The resident felt guilty sinful, or worthless; -The resident had lost interest in doing things; -The resident said there was things that frightened him/her or that worried him/her, but did not say what those things were; -The resident had thought about hurting or killing self in the past; -Observations: Mood depressed. Flat affect. Insight fair with poor judgment; -Mood: Moderately depressed; -Affect: Flat or [MEDICATION NAME]; -Threat to self/others: No threat to self or others; -Major Mental Illness: Personality Disorder (a deeply ingrained and maladaptive pattern of behavior of a specified kind, typically manifest by the time one reaches adolescence and causing long-term difficulties in personal relationships or in functioning in society); -Long history of psychiatric issues with treatment with symptoms inclusive of anxiety, crying spells, self-harm gestures, periods of aggressive behavior, and depressed mood. Past history of suicide attempts; -Individual weaknesses: Self harm behavior; -Behavioral/Mental Condition: Monitor behavior/verbal support/as needed medications as indicated/positive reinforcement; -Describe the reason for referral to nursing facility: Requires supervision for safety and medication administration. Review of the resident's discharge summary from an outlying hospital, dated [DATE], showed the following: -Reason for Admission: Danger to self; -Discharge Diagnosis: [REDACTED]. Review of the resident's facility face sheet, showed the following: -admitted : [DATE]; -Admit Diagnosis: [REDACTED]. -Current Diagnoses: [REDACTED]. -The resident was under guardianship. Review of the resident's physician's orders [REDACTED]. The resident was noted to be allergic to cinnamon. Review of the resident's care plan, dated [DATE] showed the following: -Impaired thought process - monitor and document behavior and status and report any change to physician as needed; Updated of [DATE] code green, attempted to climb tree outside, refusing to take meds, states self harm, one-on-one for four hours, educated on coping skills; -Feeling down, depressed or hopeless - schedule a visit with facility psychiatrist, observe for changes in mood status, monitor for suicidal ideation, evaluate effectiveness of medication and notify physician with changes, report of night terrors; -At risk for falls - monitor for changes in condition falls, monitor for ideas of self-harm, monitor for changes in condition that may warrant increased supervision/assistance and notify the physician, at risk for self-harm, do this for attention and on purpose, at risk for self harm. Updates noted of [DATE] found in shower on floor, [DATE] fall/code green, [DATE] fell and hit head on bedside table with scratch to forehead; -Displays socially inappropriate/disruptive behavior- Staff to monitor and document behavior. Noted the resident to eat non food items seeking attention. Updates included [DATE] increased behavior received [MEDICATION NAME] IM 5 mg/ml, [DATE] demonstrates cheer routine at nurses station randomly seeking peer attention, [DATE] confused behavior, [DATE] found sleeping on bathroom floor, appeared confused, -Independent with activities of daily living and continent of bowel and bladder - report any changes in condition to physician immediately. Review of the resident's departmental notes dated [DATE] at 9:18 A.M., showed the resident approved for care at this facility. Administration has agreed that this facility can meet the needs of this resident. Review of the resident's departmental notes dated [DATE] showed the following: -At 2:12 P.M., no suicidal ideation noted today; -At 1830 (6:30 P.M.) the Assistant Director of Nurses (ADON) called to the resident's room for emergency. Resident found siting on floor with (vomit) noted in hair, on clothes, and on floor. Resident said she fell after trying to get up from the side of the bed and hit her head. Assisted to stand but was unable to stand without two person support, appears pale and in distress, unable to say whether or not she had a [MEDICAL CONDITION] before fall. As ADON attempted to clean the resident's room, called immediately to shower room for further incident. Certified Nurse Aides (CNAs) said resident had a second fall as she vomited, sliding off the shower chair to the floor. Review of the resident's departmental notes dated [DATE] at 1000 (10:00 A.M.) showed the resident was monitored at meals due to history of purging. Continue to monitor for voiced thoughts or acts of self harm. Review of the resident's departmental notes dated [DATE] showed: -At 2200 (10:00 P.M.) response to a call light in the shower room finding resident on floor. Resident informed showers would need to be supervised for safety and to prevent falls; -At 3:30 A.M., Code Green called, the resident refused vital signs, lungs clear at this time, the resident woke up crying and yelling saying, someone is going to kill me. The resident proceeded attempting to put foreign objects in mouth to swallow, code team called and the resident continued to attempt self-harm. Physical calm team utilized for a 5-person hold for resident safety, [MEDICATION NAME] (antipsychotic medication) 5 milligrams/milliter (mg/ml) injection administered by writer per physician order. Resident continued to be delusional at that time. Items removed from resident's room that could potentially be harmful, the resident was placed on one-to-one at this time for protective oversight. Administrator, guardian, and physician notified, will continue to monitor, continue with plan of care. Review of the resident's Incident Report dated [DATE] at 3:00 A.M. showed the resident woke up crying and yelling stating, someone is going to kill me. Resident proceeded attempting to put foreign objects in mouth to swallow, code team called resident continues to self harm . Physical calm team utilized for a five person hold and [MEDICATION NAME] 5 mg/ml administered per physician's orders [REDACTED]. Resident's primary care physician notified. Review of the resident's departmental notes dated [DATE] showed the following: -At 10:25 A.M. resident near nurses desk performing a cheer routine with a peer. Encouraged resident to save those activities for outside times for safety of herself and others; -At 12:59 P.M. Resident noted to be sitting on his/her bed with a dazed look on his/her face, seemed confused and slow to respond. Resident began to improve and said she felt dehydrated, encouraged to drink, ice water provided. Review of the resident's Admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff showed the following: -Resident was cognitively intact; -Had mood indicators including feeling down, depressed or hopeless; -Had other behavioral symptoms; -Independent to transfer and walk; -Always continent of bowel and bladder. Review of the resident's departmental notes dated [DATE] at 12:19 P.M., category: resident interview, role administrator showed the following: -Code green called to the court yard, when arrived, the resident was in a two person hold due to he/she was trying to climb a tree. The resident said he/she was leaving. The resident was escorted back to his/her room with a two person escort. The resident continued saying he/she did not want to be here. He/she said he/she was not trying to leave, he/she was only climbing the tree so he/she could fall and harm him/herself. Allowed him/her to vent and would correct his/her story when he/she would tell a different story than previously told. Placed on one-to-one. Review of a Fax Transmission dated [DATE] showed the resident was out in the courtyard at smoke time and tried to climb a tree. The CNA stopped the resident and a code green was called and the resident placed one on one. Fax sent to the resident's primary care physician (same physician noted on the resident's physician orders). The fax showed a type response, Noted, thank you. Review of the resident's departmental notes, dated [DATE] at 3:00 A.M., showed the resident came running out of his/her room saying someone was in his/her room (niece) behind his/her bed. This writer and other staff showed the resident that there was no one else in the room. The resident started running in the halls looking at every door and window. Administration notified. Staff intervened with resident sitting at the table, this writer gave resident [MEDICATION NAME] 5 mg IM while sitting in the chair with the other staff talking to him/her and holding his/her hand, resident walking in the halls. This writer explained to him/her that he/she needed lie down and rest. He/she continues to be very suspicious and anxious. Placed on one-to-one for protective oversight. Review of the resident's departmental notes dated [DATE] at 3:08 P.M. showed the resident had just fallen and hit head. Resident found sitting on floor, with legs bent up under him/her, reports he/she fell . Resident had a hairline scratch measuring 1.0 centimeter (cm) to right frontal lobe of forehead about brow line. Resident states she was nauseated and gets dizzy and this was why she fell . Review of the resident's departmental notes dated [DATE] 3:41 P.M. showed the Director of Nurses (DON) said the resident continues to display attention seeking behaviors repeatedly. All of this was documented from previous placement/hospital stays as well. Review of the resident's departmental notes dated [DATE] 7:09 P.M. showed the ADON noted the resident came to her office three times today, sobbing and tearful with each encounter, yet resident immediately asked the same questions that have been addressed the previous three days. Encouraged resident to develop other coping skills as she states that he/she only wants to speak with staff when he/she is stressed or having negative behaviors. Suggested reading, watching TV/movies, walk outdoors, work on craft projects, etc. Review of the resident's departmental notes, dated [DATE] showed at 6:30 P.M. the Certified Nurse Aide (CNA) got this writer and took the writer to the table where the resident was sitting. Resident had a bowl with apple crunch in it in front of him/her with some on a fork in his/her hand. He/she said he/she was going to eat it even though it had cinnamon in it and he/she was allergic to cinnamon so that it would cause a reaction and he/she said he/she would sue the place. The writer took the dish away from the resident, offered a fresh apple and went to the kitchen and got him/her a banana. This writer talked with the resident and explained to him/her that this was doing harm to him/herself if he/she was to eat the dish of food. The resident became very argumentative with the writer and resident care coordinator (RCC). Both staff tried to explain that he/she was not making good choices. Administration notified. As needed (PRN) given orally after a long discussion about it. Resident placed on one-to-one for protective oversight, physician notified and guardian. Continues on one-to-one at this time. Notes at 11:03 showed the resident continued to require one on one supervision due to threats of self harm Resident needs supervision with all ADL's due to self harm while bathing. Review of the resident's departmental notes dated [DATE] at 5:49 P.M., showed the resident was seen by the psychiatrist during psychiatric rounds today. New order received. Review of the resident's Long Term Psych Management note, dated [DATE], showed the following: -Active Diagnoses: [REDACTED]. -Chief complaint: Self harming behavior; -History of present illness: Seen today to establish care with this program. Since the resident has been in the facility, he/she has been showing lots of self-harm behavior. He/she goes to the bathroom and tries to put gloves in his/her mouth to choke. He/she has been on one-to-one lots of times. Social history includes sexual abuse at age five by a family member. Judgement poor, absent of suicidal intent. Review of the resident's departmental notes dated [DATE] 1:25 P.M. showed the resident found sleeping in the bathroom with a pillow, confused and disoriented, states do you want me to go back in the closet? Unable to identify staff or current location. Resident placed in line of sight to monitor. Review of the resident's departmental notes dated [DATE] showed the following: -At 1:59 A.M., showed the resident was found in fetal position on the bathroom floor incontinent of urine. Noted the resident holding toilet paper in his/her hand. The resident was breathing, noted moderate amount of saliva coming from mouth. The resident was not responding to verbal commands to spit out what was in his/her mouth. Finger sweep done with gloved finger, the resident attempted to bite this writer as writer attempting to clear throat. Unsuccessful the first time. Instructed the resident to spit out what was in his/her mouth, the resident did not follow the command. Finger sweep attempted a second time; the resident did not attempt to bite this writer at that time, but still unsuccessful in removing item. Encouraged resident to spit out what was in his/her mouth again, the resident refused. Finger sweep performed a third time and an egg sized amount of toilet paper removed from mouth. The resident dry heaved at that time. When asked why he/she had done that he/she simply said, My uncle. The resident was placed on one-to-one for protective oversight at that time. Notified administration; -At 2:34 A.M. CNA sitting one-to-one with resident requested this writer come to resident's room, upon entering the room this writer noted resident to be sitting up in bed holding neck as if he/she was choking. Noted resident to be breathing without difficulty from nose. Resident then spit up a clear mucus type substance. This writer assisted resident with changing soiled clothing and bedding, after a short period resident looked at this writer and asked, Who are you? Advised resident that writer was the charge nurse on the unit tonight -At 10:30 A.M. the resident woke from sleeping incontinent and thinking people were in the room that were not, very delusional. -At 1:37 P.M. met with IDT (interdisciplinary team) today. The resident has had multiple behaviors over the last several days. Have offered potential coping interventions. Continues to have the same behaviors repeatedly. Review of the Resident Incident Report dated [DATE] at 2:00 A.M. for a choking episode noted the resident was found in a fetal position on the floor in the bathroom, had been incontinent of bladder. Resident choking on toilet paper. Finger sweep performed three times. Removed egg size amount of toilet paper from mouth/throat. Placed one on one for protective oversight. Primary care physician notified. No notation the resident's psychiatrist was notified. Review of the resident's physician orders [REDACTED]. Review of the resident's departmental notes dated [DATE] at 10:55 A.M. showed a Social Service update. Staff attempted to educate the resident on his/her behaviors and explain the consequences that could possibly occur from those actions. Staff explained that self harming behaviors often time don't mean to end the way that they do and staff does not want to see that for the resident. The resident sat and stared at staff and kept saying, hmm. Review of the resident's departmental notes dated [DATE] 10:45 A.M. showed the resident continues to need redirection not to linger at the nurses station, resident said he/she was placing chairs in front of the bed in order to keep him/her in bed when he/she has night terrors. Staff redirected resident stating this behavior was a fall risk. Review of the resident's departmental notes dated [DATE] at 10:08 P.M., showed the resident has been speaking one-to-one with the charge nurse this evening. Allowed to vent, difficulty with coping with his/her past problems. He/she has been very upset this evening saying that a resident touched his/her arm and it brought back memories of his/her past. Encouraged the resident to journal and seek staff for one-to-one time. Resident has showered this evening. Review of the resident's departmental notes dated [DATE] at 6:33 A.M., noted as an addendum, showed one-to-one time spent with the resident regarding his/her concerns with dealing with his/her past and being able to cope. Allowed the resident to vent feelings to this writer for approximately 20 minutes. The resident seemed to accept this writer's suggestions on using coping skills of journaling and seeking out staff to talk. A room search done without incident due to history of eating non-food items. The resident approached this writer multiple times this evening asking his/her normal questions. He/she was seen laughing with staff and peers, interacting appropriately. The resident voiced no suicidal/homicidal ideations at that time. Staff completing 15 minute face checks on the resident. Review of the resident's departmental notes dated [DATE] 3:38 P.M., Late Entry Charge nurse, showed called to resident's room at approximately 12:00 midnight by CNA. Found CNA holding resident up by the legs. The resident was found with a sheet tied around his/her neck as well as the TV wall mount. The resident was not responsive to verbal or tactile stimuli, and there appeared to be no signs of life. A faint pulse was detected at his/her right wrist. Called for code blue for the resident called for 911. Assisted CNA to untie the sheet and lower the resident to the floor then CPR was started. CPR continued until EMS arrived and determined that the resident had no pulse and was not breathing. CPR stopped per EMS instruction. Interview on [DATE] at 3:00 P.M., showed Resident #16 said he/she was at the medication room waiting for an as needed (PRN) medication prior to the incident with Resident #13 and that is when he/she saw Resident #13 come out of his/her room with his/her shoulders drawn up and rubbing his/her neck. Resident #16 said he/she told staff to really watch Resident #13 because he/she was going to do something. Resident #16 said he/she had attempted suicide his/herself before and knew the resident was troubled and something was wrong. The staff ignored Resident #16 and he/she overheard the staff say, 20 minutes later, I came back and she was hung. He/she had told staff three times while waiting on medications that they really needed to watch the resident that he/she was going to do something. Interview on [DATE] at 12:00 P.M., showed Resident #1 said the resident had tried to commit suicide before. He/she had attempted to climb a tree, ate toilet paper and ate soap. During an interview on [DATE] at 2:18 P.M., Resident #18 said Resident #13 was his/her roommate. Resident #18 said Resident #13 told him/her about another resident touching him/her on the arm. Resident #18 asked the staff about it and staff said Resident #13 took it as sexual. Resident #18 said that staff asked him/her to keep an eye out for Resident #13 and they did that a lot. Resident #18 said he/she fell asleep and woke up when a staff member was holding the resident up and screaming for help. Resident #13 was still hanging with a sheet tied around his/her neck and to the television stand on the wall when he/she woke up. Interview on [DATE] at 3:13 P.M., showed CNA A said the following: -He/she came on shift on [DATE] at 7:00 P.M., he/she got report from the off-going staff and when he/she reached the 600 hall the off-going staff said Resident #13 had been upset due to him/her being touched on the arm by another peer; -He/she then got 15 minute face checks paperwork and went down 600 hall and couldn't find the resident in his/her room, in his/her bathroom, or in the dining room. Other residents on the unit said he/she had been in the shower/bathroom all day. CNA A got the key to the shower/bathroom and knocked, but heard no answer. CNA A then opened the door and the shower curtain was pulled and the shower room area was dark. CNA A then pulled the curtain and noticed the resident sitting in the corner of the shower room facing the corner with his/her knees pulled up and his/her head bent forward. The resident would not tell CNA A what was wrong, so he/she went and got CNA B. CNA B then went into the shower room and attempted to see what was wrong and informed the resident that he/she couldn't be in the shower room and that he/she needed to talk to someone. Licensed practical nurse (LPN) C then came into the shower room and started talking to the resident on the floor, telling him/her that he/she had to get up, the resident was saying nothing, nothing. Staff helped the resident up and LPN C went with him/her to his/her room and talked to him/her. CNA A then started his/her work. LPN C came out and came to the desk saying the resident said another peer had touched his/her arm and his/her breast and he/she reminded him/her of someone in his/her past that had molested him/her. CNA A and CNA B were checking on the resident every 15 minutes. On one of the 15 minute checks the resident was playing with something in his/her room under the covers and acting suspicious. CNA B informed CNA A that he/she had just checked on the resident at 11:30 P.M. CNA A was warming up his/her supper and decided to go check on the resident at 11:50 P.M. When CNA A went into the resident's room, he/she found the resident hanging from the television stand with a sheet. CNA A immediately hollered for help and raised the resident up off the ground as his/her feet were touching the floor. LPN C entered the room and assisted getting the resident down and started CPR. Another resident had been telling the staff to keep an eye on the resident that night. Review of CNA A's written statement, dated [DATE], provided by the facility, showed he/she said the resident was in the shower room when he/she came on the hall at 7:00 P.M. He/She could not find the resident, he/she found him/her in the corner of the shower. They knew something was wrong so he/she and CNA B tried to talk to the resident. He/She got the charge nurse, he/she took the resident to his/her room and talked. The resident seemed to do better, he/she took a shower and came out , the charge nurse wanted us to watch the resident so they checked his/her room to see if he/she had anything in there he/she might have been trying to do something with. The resident went to bed, every 15 minutes they checked the resident and he/she was in bed. CNA B checked him/her at about 11:30 P.M. or a little after, and CNA A said he/she sat down to eat. He/She finished around 10 till 12:00 midnight (11:50 P.M.), he/she went to check 600 hall and the named resident. He/She found the resident with a sheet tied to the television stand on the wall with his/her neck in the sheet. He/She grabbed the resident's legs and yelled for the charge nurse, they untied the resident and called code, CPR was started with four other staff and CNA A. First responders started defibrillator on the resident, the resident had a pulse when they were working on him/her.

Based on observation, interview and record review, the facility failed to adequately evaluate and assess one resident's ,(Resident #25's) of ten sampled residents', medical and psychosocial status prior to admission to the facility to ensure the facility could meet the resident's needs. The facility obtained information that showed the resident had recently assaulted another resident in a different facility and a security guard at a hospital. The resident required the use of antipsychotic medication. Upon admission, facility staff incorrectly transcribed the resident's medications and administered the incorrect medications during the course of the resident's four day stay. On 8/18/13, the resident attacked another resident (Resident #50), in the dining room area, striking the other resident multiple times in the back of the head, knocking the resident to the floor, as well as punching two staff members in the face without provocation. Resident #50 and both staff members required medical treatment. The facility census was 111. 1. Review of the facility's nursing admission policy (undated), showed the admission team consisted of the Admissions Coordinator, Social Service Director, Director of Nursing (DON), and Administrator. The team would meet and review each perspective resident's history and physical, recent nurses notes, medication list, psychiatric evaluation, medical evaluation, diagnoses, any special needs or requirements, current level of care, past history including the history and decompensation of medical and mental health. The team would review each [DIAGNOSES REDACTED]. The team would assess individually the whole person. The physician would be consulted upon admission of the resident on the primary [DIAGNOSES REDACTED]. *After reviewing the individual resident each team member will discuss concerns or issues of admitting the resident. Each team member will give input on whether the resident is an appropriate admission to the facility. The team will discuss the impact of the resident who has dual [DIAGNOSES REDACTED]. If a team member denies admission they will put in writing the reason for denial, at which time the team will have the opportunity to discuss reason for denial. The team may request more information. If the team requests more information, then the team will meet again to review the new information before finalizing a decision. The final decision for admission or refusal to admit will be left up to the Director of Nursing , and ultimately the Administrator. *If the decision is made to admit the resident then the Admissions Coordinator will obtain all pertinent information to ensure that the resident's need can be met including: current drug regimen, diet orders, laboratory orders and any special need items. *A Licensed/Registered Nurse will ensure that all admission paperwork including physician orders, medications, diet orders, laboratory orders etc. are followed. Medications will be ordered from the pharmacy of resident/guardian's choice. 2. Review of the facility's Behavioral Emergency Policy (undated) showed it was the policy of the facility to provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished or disciplined for staff convenience. If the resident exhibited extreme behaviors such as suicidal, homicidal, self-mutilation, elopement or resident to resident altercations, the licensed nursing staff/team leader or Resident Care Coordinator (RCC), would assess the resident who was exhibiting the behaviors, ensure the safety of the resident and others was the first priority. A one to one monitoring of the resident would be initiated at this time under the direction of a licensed nurse. 3. Review of the facility's instructor's CALM (Crisis Alleviation Lessons and Methods) manual, the behavior management program the facility uses to educate and train all staff regarding behavioral crisis situations, Chapter 4: Baseline Behavior, showed the program directed the emphasis of verbal de-escalation was recognizing changes in established patterns of behavior. In order to develop a therapeutic relationship, the CALM program identified client history as a component. Exploring the resident's family history, history of abuse, chemical dependency, and criminal history were identified areas which could assist staff in establishing patterns of behavior. 4. Review of Resident #25's medical record showed documents which had been faxed to the facility from his/her previous facility. Review of the previous facility's admission nursing note showed the resident had been admitted to previous placement on 05/21/2013. The admission nursing note showed the resident hit another resident in a previous mental institution and had spent six months in jail. Nurses notes showed on 06/03/2013, the resident was admitted to a psychiatric hospital and was discharged back to the previous facility on 06/14/2013. Review of a hospital history and physical dated 06/23/2013 showed the resident was admitted to a psychiatric hospital (from previous placement) after striking a security staff in the emergency room and required chemical restraint. The resident discharged back to the previous facility on 07/04/2013. Review of the previous facility's resident's history and physical dated 06/23/2013 showed the resident was admitted to the psychiatric unit after an acute exacerbation of schizophrenia. The resident had failed treatment with several antipsychotics (psychiatric medication used to manage delusions, hallucinations or disordered thoughts in those with schizophrenia or bipolar disorder). Given no response to several antipsychotics, the resident was started on clozapine (antipsychotic). The plan was to discontinue the resident's ativan, increase Risperdal (antipsychotic) to 3 milligrams (mg) twice daily and start Clozaril (clozapine) 25 mg at bedtime. Review of a discharge letter dated 06/25/2013 to the resident's guardian showed the previous facility was not able to meet the resident's needs and was giving the resident a 30 day notice of discharge. The facility identified the resident's psychiatric needs were greater than the scope of practice for the facility. The resident was currently in a neuro-psychiatric unit and this was his/her third admission in about 30 days. During the short time the resident was in this facility he/she refused to follow his/her medication regimen by refusing doses of medications, frequently reported active hallucinations to other clients or staff and often smoked in non-designated areas. The resident constantly stated that he/she did not want to live at this facility and staff felt the resident was a constant elopement risk. Review of the resident's Level II screening, (pre-admission screening to determine if they have been placed appropriately for care), dated 06/27/2013, showed the resident had a [DIAGNOSES REDACTED]. Potential problem areas included failed treatment with several anti-psychotic medications, florid psychotic symptoms, insight and poor judgment. The assessment identified the resident needed maximum staff assistance in monitoring for delusional behavior and elopement risks, administering medications, monitoring the effects of the medications and compliance with medications, redirecting and providing reality orientation, antipsychotic medication management to be monitored closely. The resident had been given a 30 day notice to move from the previous facility. Review of the resident's nurses notes from the previous facility showed on 07/12/2013 the resident was sent to a psychiatric hospital due to striking his/her roommate twice. The resident was sent back to the facility. Review of the resident's physician orders [REDACTED]. -Lexapro (antidepressant), 10 mg, one by mouth daily at 7:00 A.M.; -Zantac (used to treat heartburn), 150 mg, one tablet by mouth twice daily at 7:00 A.M. and 4:00 P.M. -Artane (used to treat side effects of antipsychotic medications), 5 mg, one tablet by mouth twice daily at 7:00 A.M. and 4:00 P.M. -Abilify (antidepressant), 400 mg, IM (intramuscular injection) every 30 days; -Clozaril (antipsychotic), 100 mg, 1 ? tablets (total dose to equal 150 mg.) twice daily at 7:00 A.M. and 8:00 P.M. -Risperdal (antipsychotic), 3 mg, one tablet by mouth twice daily at 7:00 A.M. and 8:00 P.M. -Ativan (antianxiety), 0.5 mg, one tablet by mouth twice daily as needed for agitation. (These orders indicate the current medications the resident was taking when he/she was discharged from the previous facility on 08/14/2013). Review of the resident's Medication Administration Record (MAR) from the previous facility dated 08/01-08/31/2013, showed a medication order for Ativan (antianxiety), 0.5 mg (milligrams), one tab by mouth twice daily as needed for agitation. Review showed facility staff documented administering 19 doses of Ativan between Aug. 1 - Aug. 14, 2013. The resident was discharged on [DATE]. Review of the resident's medication release document showed the following physician ordered medications had been released with the resident when he/she was discharged from the previous placement on 08/14/2013; -Lexapro 10 mg., thirteen tablets; -Zantac 150 mg., twenty-nine tablets; -Artane 5 mg., twenty-eight tables; -Clozaril 100 mg., one tablet; -Risperdal 3 mg., nine tablets; -Clozaril 100 mg. fourteen tablets and -Risperdal 3 mg., twenty four tablets. Review of the resident's nurse's note dated 08/14/2013 at 1:00 P.M. from the resident's prior facility, showed two male staff from the long term care facility where the resident was being transferred to were there to pick up the resident. The resident was given a prn (as needed) medication, packed lunch, sent medications, MAR's (medication administration record) and POS's (physician order [REDACTED]. 5. Review of the resident's nurse's note dated 08/14/2013 at 6:20 P.M., showed the resident was admitted to the facility, medications had been verified and sent to the pharmacy. Review of the resident's initial care plan dated 08/14/2013 showed the following problems and interventions: -Paranoid delusions: monitor medication compliance, assess behaviors, teach to use coping skills. To be done every shift and as needed; -Verbal and physical aggression: monitor medication compliance, contact physician and management team on behaviors and administer prn's as directed, redirect and rechannel behavior prn; -Elopement risk: 1:1 staff approximately five hours when first arrives, then five minute face checks, monitor behavior for increased agitation, console with resident; -Communication skills: encourage group, introduce to peers and staff and encourage conversation. Interview on 09/10/2013 at 3:30 P.M. showed Licensed Practical Nurse (LPN) G said he/she completed the initial care plan for Resident #25. He/she obtained the information for the care plan from a previous hospital history and physical and the resident's diagnoses. He/she identified interventions based on what he/she had learned in nursing school. Review of the resident's physician order [REDACTED]. -Ativan, 0.5 mg, one tablet by mouth three times daily at 8:00 A.M., 2:00 P.M. and 8:00 P.M.; -Risperdal 2 mg, one tablet by mouth twice daily at 8:00 A.M. and 5:00 P.M.; -Lexapro 10 mg, one tablet daily at 8:00 A.M.; -Artane 5 mg, one tablet twice daily at 8:00 A.M. and 5:00 P.M.; -Zantac 150 mg., by mouth twice daily at 6:00 A.M., and 5:00 P.M.; -The physician's orders [REDACTED]. twice daily, Risperdal 3 mg daily and Ativan 0.5 mg prn. Review of the resident's MAR (Medication Administration Record) dated 08/01/-08/31/2013 showed facility staff documented administering the following medications 08/15/2013 through 08/18/2013: -Ativan 0.5 mg, one tablet at 8:00 A.M., 2:00 P.M. and at 8:00 P.M.; -Risperdal 2 mg, one tablet at 8:00 A.M., and 5:00 P.M.; -Artane 5 mg, one tablet at 8:00 A.M., and 5:00 P.M.; -Zantac 150 mg, one tab at 6:00 A.M. and 5:00 P.M.; -The facility did not document administering Clozaril 150 mg. twice daily, Risperdal 3 mg daily or Ativan 0.5 mg prn that should have been ordered. During an interview on 08/21/2013 at 4:00 P.M. the DON said: When the resident was admitted to the facility on [DATE], LPN E had taken a medication list from a previous hospital history and physical dated 06/23/2013 and this was the medication list that was verified with the resident's physician, instead of the current medications the resident had been prescribed. The physician approved the medication list. These were the medications the resident was taking prior to his/her hospitalization on [DATE]. Review of the resident's nurses notes dated 8/15/13 through 8/18/13 showed the following: -On 08/15/2013 at 9:30 A.M., the resident was very quiet and kept to him/herself in his/her room; -On 08/16/2013 at 9:15 P.M., the resident was spending most of the evening in his/her room; -On 08/17/2013 at 9:55 A.M., the resident was quiet and kept to self; -On 08/18/2013 at 6:15 P.M., the resident was in the dining room with other residents and for no apparent reason, the resident began hitting another resident in the head. A code green (the facility's system to alert staff of a crisis situation) was called and staff attempted to intervene and staff was hit in the face, two staff members were injured before the resident was contained. The resident was contained with a take down. All of the injured were treated and the resident was placed on one on one monitoring, currently 5 on 1 in room waiting on orders to discharge to an area psychiatric hospital. Review of a behavior-monitoring document dated 08/18/2013 and completed by Certified Nurse Aide (CNA) D showed the resident was walking around in the dining room from 6:15 P.M. until 6:30 P.M. From 6:35 P.M. until 10:00 P.M., the resident remained in his/her room with noted anxious/upset behaviors during this time. Review of an immediate notice of discharge letter dated 08/18/2013 showed Resident #25 was being discharged from the facility due to the facility not being able to meet the resident's needs. The reason for the discharge was un-redirectable aggressive behavior that endangered the safety of the resident and the health and safety of individuals and staff in the facility. Specifically, Resident #25 began punching another resident in the head, knocking him/her to the floor and then began kicking him/her while he/she was on the floor. This was an unprovoked incident. There was no conversation or confrontation prior to this attack. Resident #25 then attacked two staff members while they were attempting to assist the injured resident. Resident #25 caused a laceration to the right side of the forehead just above the brow to one staff member, and broke the glasses and caused a laceration to the bridge of the nose to the other staff member. The injuries were caused by Resident #25 hitting them with a closed fist. 6. Review of <http://www.pharma.us.novartis.com/product/pi/pdf/Clozaril.pdf> (pharmaceutical company that developed and markets Clozaril), showed Clozaril is indicated for the treatment of [REDACTED]. In the event of planned termination of Clozaril therapy, reduce the dose gradually over a period of one to two weeks. If abrupt discontinuation is necessary (because of agranulocytosis or another medical condition, for example), monitor carefully for the recurrence of psychotic symptoms and symptoms related to cholinergic rebound such as profuse sweating, headache, nausea, vomiting, and diarrhea. 7. Review of Resident #50's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff dated 07/06/2013 showed the resident had no cognitive impairments, no behaviors and was independent with all activities of daily living. During an interview and observation on 08/20/2013 at 10:15 A.M. showed Resident #50 said his/her head and eye hurt. He/she had just returned to the facility after being gone for seven days with family. He/she went into the dining room for dinner, sat down, ate dinner and Resident #25 came up from behind him/her and struck him/her from behind several times in the back of the head. Resident #25 knocked him/her onto the floor and then Resident #25 went after CNA A and pounded him/her right in the nose. Resident #25 knocked CNA A up onto a table. He/she said he/she was not sure where the charge nurse was but knew that he/she had gotten hit as well because he/she saw LPN B at the hospital. Resident #50 thought the police had gotten Resident #25 contained. Resident #50 said he/she told one of the police officers he/she wanted to press charges against Resident #25. Resident #50 said he/she had knots on his/her head and was observed to have steristrips to the corner of his/her left eye. The area around his/her left eye was reddish/purple with swelling present. (Review of the resident's medical record showed he/she was treated at a local hospital for a laceration to his/her right eye and contusions and was released back to the hospital). During an interview on 08/20/2013 at 1:15 P.M. Resident #75 said: He/she was in the dining room and all he/she knew was he/she heard someone say "fight" and then he/she saw Resident #50 get hit once or twice. His/her initial reaction was to get out of the way. He/she fell trying to get out of the way, and by the time he/she got up Resident #50 was on the floor. All he/she remembered seeing was Resident #25 hitting CNA A in the face, then he/she nailed LPN B 2-3 times. Resident #75 said he/she picked up a chair and was going to do what needed to be done. Resident #75 said he told Resident #25 he/she was not going to do that again. Later, Resident #25 got pretty calm and collected. Resident #75 said Resident #25 told staff that he/she heard voices. During an interview on 08/21/2013 at 3:35 P.M. CNA A said he/she was working the 7:00 A.M. to 7:00 P.M. shift on the secured unit of the facility where Resident #25 resided. There was nothing significant that happened during the daytime hours of his/her shift. He/she was at the nurse's station and had his/her back to the dining room tables and he/she heard someone yell, " fight ". He/she turned around and saw Resident #25 hitting Resident #50. Resident #25's swings were pretty wild but he/she was making contact, most definitely in the head, with Resident #50. CNA A stepped forward to break it up and Resident #50 was still sitting in the dining room chair, which was quite surprising because he/she was taking quite a beating. As CNA A moved towards the two residents, Resident #25 took a couple of steps away from him/her, turned around and hit CNA A in the face twice with his/her fist. CNA A backed up and Resident #25 hit him/her again. After that, CNA A was not sure if Resident #25 knocked him/her into a table but he/she ended up laying on top of the table and bringing his/her legs up to protect him/herself from Resident #25. Resident #25 then started going in the direction of the 600 hallway. Another resident (Resident #75) had become angry and had picked up a chair but didn't act like he/she was going to throw it. CNA A was not sure at what point LPN B had been struck by Resident #25. CNA A was treated in and released from a local emergency room . He/she received three stitches and now had bruising under both eyes. CNA A had worked on the previous two days before this incident and said Resident #25 didn't interact much with other residents. CNA A said Resident #25 wasn't quite there. CNA A said he/she was not aware of the resident reporting of hearing any voices. CNA A was not aware of any history of aggressive behaviors of the resident. Review of the facility written statement completed by CNA A dated 08/18/2013 showed: At approximately 6:15 P.M. Resident #25 attacked Resident #50 without provocation. Resident #25 began hitting Resident #50 in the head with both fists. CNA A ran toward the two and as he/she got there, Resident #25 hit CNA A once or twice in the forehead. CNA A backed up and Resident #25 came after him/her again and hitting him/her on the bridge of the nose. CNA A laid back onto a table and raised his/her legs so Resident #25 could not get any closer to him/her. Resident #25 backed up and then CNA A got off the table and was going to pursue Resident #25 again. Another resident (Resident #75) began to tell Resident #25 to stop. LPN B told Resident #75 to stop and backup. At that point staff from station one appeared and the situation was de-escalated. LPN B said he/she was treated and released from a local hospital for a puncture wound above his/her right eye from Resident #25's fist. During an interview on 08/20/2013 at 2:00 P.M. CNA F said he/she was assigned to work the 400 hall on 08/18/2013 from 7:00 A.M. until 7:00 P.M. He/she was in the back of the dining room picking up trays. There were a lot of residents in the dining room because only two residents had requested halls trays for the evening meal. Resident #50 was bent over in a chair and was trying to cover his/her head and Resident #25 was punching him/her. CNA A asked Resident #25 what he/she was doing and Resident #25 spun around and started punching CNA A in the face, then pushed CNA A into a table. CNA A fell back onto the table and Resident #25 went back and started punching on Resident #50 again. By this time a code had been called. LPN B went over and tried to calm Resident #25 down and he/she spun around and started punching LPN B in the face. CNA F said during the 4:30 P.M. smoke break that day, Resident #25 told him/her that cigarettes make him/her do bad things. He/she said resident #25 isolated him/herself. During an interview on 08/21/2013 at 1:34 P.M. CNA D said he/she was working on the 300 hall on 08/18/2013. A staff person from the kitchen came to him/her and said they needed any available staff that could to respond to the code green on the secured unit. He/she entered the secured unit, a resident (Resident #25) was walking towards him/her. He/she did not know Resident #25. Staff motioned to CNA D that the resident was Resident #25. CNA D turned around, called Resident #25 by his/her name and asks him/her what was up. The resident grabbed his/her hand and said he/she needed help. CNA D asked the resident if he/she wanted to walk to his/her room and the resident said he/she wanted to do that. There was four other staff standing around the doorway of the resident's room. The resident's room door was kept open. CNA D was staying in Resident #25's room with him/her by him/herself the entire time. The resident did not want anyone else in the room or he/she would "wig out". CNA D tried to talk to the resident and keep him/her calm. CNA D asked the resident if he/she knew what was going on and the resident said he/she didn't know. The resident kept coming in and of reality. The resident had a blank stare on his/her face. CNA D ask the resident if he/she could take the resident's vital signs and the resident said no. CNA D stayed in the room with Resident #25 for three hours. The resident was very calm but you could tell he/she was worried about what was going to happen to him/her. The resident kept saying he/she needed help. The resident said he/she saw people crawling out of the people he/she hurt. CNA D said he/she was with the resident from 6:10 P.M. until 10:00 P.M. He/she said he/she had never spoken to this resident prior to this event. He/she said Resident #25 did appear anxious/upset and would get up and pace the room and have a blank stare on his/her face. During an interview on 08/21/2013 at 10:55 A.M. LPN B said: He/she was giving report to LPN C and heard someone scream "fight" "fight". LPN C got on the telephone and called a code "green". LPN B came from behind the nurse's station and saw that Resident #50 was on the floor and CNA A was attempting to get Resident #25 off of Resident #50. Resident #50 was face down on the floor. He/she saw Resident #25 punch CNA A several times in the face with his/her fist. Resident #25 flung CNA A onto a table, then turned his/her attention back to Resident #50. Resident #25 began kicking Resident #50. LPN B went over to where Resident #25 was and was going to try to stop Resident #25. He/she was not sure how he/she was going to make Resident #25 stop kicking Resident #50. Resident #25 stopped kicking Resident #50 when he saw LPN B approaching, Resident #25 hesitated and then said " you too [***] " and then Resident #25 punched LPN B with his/her fist in the right eye. He/She did not think he/she fell down but did remember feeling fuzzy. He/she saw CNA A was bleeding and then realized he/she was bleeding. He/she did not remember much after that. LPN B said Resident #25 had only been in the facility for 4 days. He/she said he/she had not seen any violence from the resident. He/she said he/she had no indication that he/she had ever been violent. He/she said he/she had seen him/her a couple of times throughout the day and had not noticed anything about him/her. He/she said a code " green is called when residents become aggressive. He/she said he/she figured by the time 6 people arrived to the secured unit, Resident #50 could have been hurt very badly so he/she felt like he/she had to do something. Review of LPN B's written facility statement (undated) showed LPN B said: He/she heard "fist fight" and said code green. The other nurse grabbed the telephone and LPN B went to help. Resident #25 was punching Resident #50. When CNA A tried to pull Resident #25 off of Resident #50, Resident #25 began punching CNA A over and over again. CNA A fell back onto a table and then Resident #25 began kicking resident #50. LPN B said he/she stepped forward to try to stop Resident #25, he/she said Resident #25 looked at him/her and said "you to [***] " and then punched him/her in the face. Resident #75 was trying to help him/her and LPN B told him/her to get back. More staff came to help. LPN B was bleeding a lot and given first aide. CNA A was also bleeding a lot. Resident #50 was face down on the floor. During an interview on 08/20/2013 at 10:00 A.M. and 12:20 P.M. the DON said: The facility admitted Resident #25 on 08/14/2013 and on 08/18/2013 around 6:00 P.M., the resident hit another resident, (Resident #50). When a staff person went to help, the resident hit the staff person and hit an additional staff person. Resident #50 was sent to a local hospital for evaluation as well as the two staff who had been struck by the resident. LPN C called 911 and then hung up and did not speak to anyone. The 911 dispatcher called the facility and the facility reported an altercation and requested an ambulance to transport an injured resident. During an interview on 08/20/2013 at 2:55 P.M. the DON said: Staff called 911 to transport the injured resident to the hospital. He/she did not think what Resident #25 did was planned or purposeful. The resident was completely delusional and you couldn't carry on a conversation with him/her. It was not a vicious attack but a sick person who was having a psychiatric break. The injured resident was the number one priority, and they were waiting to get orders from the physician, making sure everyone had been informed, and a significant amount of time was spent talking to the resident to get him/her to walk out of the building, and arranging facility transporters to transport the resident. During an interview on 08/21/2013 at 9:33 A.M. the DON said: As many people as possible reviewed information on potential residents. A decision was made if the potential resident was appropriate for services. The facility would sometimes call and speak to the resident's guardian. During an interview on 09/05/2013 at 10:30 A.M. the resident's guardian said: No one from the facility had contacted him/her requesting any information regarding the resident's history or behaviors prior to the resident being admitted to the facility. He/she did receive a telephone call from a staff person at the facility stating they would admit the resident to the facility. He/she said assault charges were filed against the resident when he/she struck the security guard. He/she said the resident was placed on probation for two years and received a fine. When the facility discharged the resident to a psychiatric hospital on [DATE], he/she spent 8 days there and was discharged to another facility. On his/her third day at this other facility, the resident swung at a therapist but no contact was made because the therapist ducked. The resident then eloped from this facility and was sent back to the psychiatric hospital. The resident was a danger to him/herself and others. During an interview on 08/22/2013 at 9:30 A.M. the resident's physician and medical director of the facility said the following: -He was not familiar with Resident #25 and did not know his/her history, had not met him/her or completed any type of assessment on him/her; -LPN E did not follow the facility's policy and procedure when admitting Resident #25. LPN E had used a medication list from a history and physical that was dated 06/23/2013. The resident was hospitalized at that time because those medications were not effective for the resident. The facility staff were suppose to use the resident's latest MAR along with the transfer form; -The residents psychotropic medications were monitored by a psychiatrist; -As the medical director, if a resident was exhibiting behaviors he would give orders for medications but he does not make changes to the residents' antipsychotic medications; -He did not know if Resident #25's psychiatric medication management was being closely monitored; -Antipsychotic medications such as Clozaril should be tapered to lower doses and the resident should be closely monitored when discontinuing therapy; - Changes in the medications from what the resident was currently taking prior to being admitted to the facility could affect the resident's behaviors, thought process and actions; -He said he would have gotten the resident out of the facility pretty quickly; -He was very rarely involved in the admission process. Sometimes if there were questions regarding a resident's weight and if there was the appropriate equipment in the facility to care for the resident or sometimes if the resident has had criminal behaviors, he may be involved; -Facility staff are in-serviced on how to deal with residents who exhibit violent behaviors and knew the facility had polices in place. During an interview on 08/21/2013 at 3:45 P.M. the Administrator said: The resident's prior placement said Resident #25 had three hospitalization s between June and August of 2013 and was disconnected from reality. In June 2013, the resident punched another resident twice. This was unprovoked and the resident who was punched was sent to the emergency room . During an interview on 08/22/2013 at 11:40 A.M. the facility Administrator said: -He expected all staff to follow the facility's policies and procedures when admitting residents; -The facility had an admission team that consisted of himself, nurses, customer service consultants, and others. The team looks at all the information that is gathered to see if the facility can meet the resident's needs. It is a full team approach; -Facility staff had spoken with Resident #25's previous facility and also his/her guardian regarding the residen

Based on observation, interview and record review, the facility failed to provide protective oversight to one resident (Resident #1), under guardianship with a history of elopement, of seven sampled residents. Resident #1 presented with a [DIAGNOSES REDACTED]. The resident eloped from a locked unit without staff knowledge. The resident stole alcohol from a local convenience store, became intoxicated, attempted to re-enter the facility, then left again followed by staff. The police were notified. The resident became aggressive with staff and police officials. The resident was maced, handcuffed and shackled by local police, then treated by the local emergency medical services due to his/her eyes being maced. The resident was returned to the facility by law enforcement. Upon return to the facility, staff gave the resident two injections of antipsychotic/anti-anxiety medication and five staff lowered the resident to the floor and held the resident there for approximately an hour until transferred to an area psychiatric hospital for evaluation/treatment. The facility census was 112. 1. Review of the facility policy and procedure elopement protocol, showed the following: -First person aware of an elopement will call a " Code White " to the area of the believed elopement; -The administrator will be called; -Notify resident's family or guardian; -Charge Nurse will initiate facility grounds search, call the police, and provide the police with pertinent information; -Administrator will initiate emergency call list and coordinate the search; -After the resident returns to the facility notify family/guardian, full body assessment, obtain vital signs, document all findings, notify physician, complete investigation elopement form, and initiate intensive monitoring protocol. 2. Review of the facility policy and procedure for intensive monitoring charge nurse/team leader accountability, showed the following: -Each charge nurse/team leader will be expected on a shiftily basis to review intensive monitoring sheets and ensure through observation that the assigned staff are completing eye to eye face checks for their designated length of time; -Charge nurse/team leader will be responsible to complete random checks on every resident on their unit and ensure that eye to eye contact is being made by trained staff; -DON/RCC (director of nursing/resident care coordinator) designee will monitor to ensure that charge nurses/team leaders are following the policy and signing random checks at least twice a shift 3. Review of the facility policy and procedure for elopement assessment precaution/prevention, showed the following: -Resident photo placed in the resident elopement profile book; -Resident will be placed on intensive monitoring. 4. Review of Resident #1's medical record, showed the resident was placed under guardianship on 08/31/12. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 12/16/12, showed the following: -[DIAGNOSES REDACTED]. -Cognitively intact; -Independent with activities of daily living. Review of the resident's care plan dated 10/01/12 and in use at the time of elopement, showed the following; -Impaired thought processes; -Risk for elopement; -Resident will receive the protective oversight necessary to maintain safety and well-being through next review; -Investigate any environmental factors which may be affecting his/her feelings and desire to elope; -If at any time the resident cannot be located and is believed to have eloped, initiate code white (procedure for what to do when a resident is missing), providing a description of the resident, clothing worn, and pertinent medical history; -Resident will be placed in elopement book along with face sheet and his/her picture; -Provide intense monitoring (1 hour checks, 30 minute checks, 15 minute checks or 5 minute checks), as specified in the resident's chart and one on one as appropriate to level of risk for elopement; -No outside smoking privileges without staff supervision. Record review of the resident's one hour licensed nurse intensive monitoring checks dated 02/12/13, showed the following: -Place a check in the box signifying the resident was seen face to face. If the resident is not on the unit, use appropriate key code to signify location; -The resident's name with a check mark in each hourly box from 12:00 A.M. to 7:00 P.M.; -No check signifying the resident's location at 8:00 P.M. box and no indication from the key where the resident was located; -The resident's name with a check mark in the hourly boxes from 9:00 P.M. to 11:00 P.M., with the 10:00 P.M. and 11:00 P.M. boxes crossed out. -Signatures of licensed staff for the 6:00 P.M. to 6:00 A.M., 6:00 A.M. to 12:00 P.M., and the 12:00 P.M. to 6:00 P.M. shifts. During an interview on 02/15/13 at 9:30 A.M. Certified Nurse Aide (CNA) B said the following: -He/She did fill out Resident #1's 30 minute check sheet for the time the resident was missing, he/she had gotten behind and did not fill them in until the resident had returned to the facility -He/She put an " O " in the box for other; he/she said he/she was not sure how to fill it out for the period of time the resident was missing. Interview on 02/13/13 at 3:45 P.M. showed the resident said the following: -He/She walked out the side door/smoke break room around 6:00 P.M. on 02/12/13; -He/She left the facility premises and walked around town, got some beer, a twelve pack, from a friend; -He/She didn't know if the facility noticed he/she was gone or not; -He/She came back to the facility after he/she had been gone awhile, looked for someone and the staff saw him/her outside; -That's when they started looking for him/her and called the police; -The police maced him/her in the face; -They brought him/her back to the facility; -He/she didn't want to be locked in his/her room so he/she resisted, and they sent him/her to the hospital. Review of the facility's investigation report completed by the ADON (assistant director of nursing) dated 02/13/13 showed the following: -On 02/12/13, CNA B took the male residents out to smoke at 6:00 P.M.; -Approximately half of the male residents were smoking outside and the other half were inside the smoking room; -Resident #1 came out to smoke at 6:10 P.M.; -CNA B did not recall the resident coming back inside the building; -At approximately 6:45 P.M., staff called a code green (multiple staff respond when there is a threat of a resident becoming violent) to the outside smoke area following an altercation between two residents (Resident #2 and #3); -CNA B did not recall Resident #1 coming back inside the building; -At 8:45 P.M. CMT (certified medication technician) D went to give the resident his/her medications; -CMT D could not locate the resident; -Staff began searching inside the facility; - LPN (licensed practical nurse) F found the gate to the smoking area unlatched and open; -Staff began to search outside; -LPN E said she had seen the resident out by the gate trying to re-enter the back gate which had been latched; -CNA G and SSD H (Social Services Director) began checking outside; -They spotted a man walking up the road and realized it was the resident; -As they tried to approach the resident, they observed the resident had a bottle in his/her hands; -They continued to follow the resident; -SSD H directed CNA I to call the police; -SSD H kept trying to talk to the resident but the resident kept walking and cursing at staff saying he/she was going to his/her family's house; -The resident began to run; -Staff ran after the resident; -The resident turned around, yelled at staff, then came running at them with a beer bottle in his/her hand (holding it over his/her head) saying he would bust their heads; -Staff gave the resident some distance, but stayed behind him/her; -The police officer pulled up and got out of his car; -The police officer tried to talk to the resident; -The resident dumped his/her beer, then turned around on the officer and staff; -The resident began running at the officer and staff; -The officer maced the resident; -The resident threw his/her bottle at the officer striking the officer in the back; -The resident sat down in the grass along side the road; -The ADON arrived at the facility at approximately 9:45 P.M.; -Staff reported the resident had been located at an intersection; -Upon the ADON's arrival to the scene, she observed the resident face down in the grass with three law enforcement officials standing near the resident; -It was reported the resident had been maced as the resident had threatened one of the deputies with a glass bottle; -The resident tried to get of the ground multiple times and continued to be verbally and physically aggressive, making threats; -The resident pulled a beer bottle out of his/her pocket and began to drink it; -Then, the resident tossed the bottle in the grass; -A fourth law enforcement official arrived; -The resident was cuffed around the wrists and ankles; -Awaiting the arrival of EMS (emergency medical services) (called by the sheriff's department) to assess the resident and rinse the resident's eyes; -At approximately 10:10 P.M., staff assisted the resident back inside the facility; -Staff gave the resident Haldol (antipsychotic) and Ativan (antianxiety) by injection, then escorted the resident up the 500 hall to the focus (quiet room) room; -Once in the focus room, the resident became very aggressive; -The resident began threatening staff, kicking and spitting; -A code green team was in place; -Staff lowered the resident to the floor using the CALM (Crisis Alleviation Lessons Method) (five person take down) technique; -The resident continued to curse, threaten and thrash about once placed on the floor; -Staff notified the physician and obtained an order to administer another injection of Haldol and Ativan to be administered "Now"; -Staff attempted to talk to the resident to calm him/her, but all attempts at redirection were unsuccessful; -The ADON attempted to assess the resident, but the resident would not cooperate and the request made the resident more agitated; -The resident responded to staff by cursing, spitting blowing his/her nose and kicking; -The resident remained in a five man hold until transportation was ready to leave; -Staff transferred the resident to a wheelchair while continuing to hold the resident; -The resident left the facility at 11:30 P.M.; -The resident was last seen in the facility at 6:15 P.M. on 02/12/13; -The resident potentially left the building between 6:30-6:45 P.M.; -Code Green was happening in the last known location of the resident; -Thought the resident used the code green as an opportunity to leave out the gate of the smoking area; -The resident was seen on camera at a local convenience store, approximately 1.34 miles from the facility, at approximately 7:10 P.M. on 02/12/13 and noted to be shop lifting various items (alcohol) before leaving the store. Note: The weather channel website showed the temperature on 2/12/13 at 7:00 P.M., was 37 degrees. The resident was wearing jeans and red hooded sweatshirt when found by facility staff and police. During an interview on 02/14/13 at 5:15 P.M. CNA A said the following: -Started smoking (assisting to smoke) the men (male residents) at 6:10 P.M.; -The male residents smoked while outside with CNA A; -Another aide, who was going to monitor the women smoke, came out and most of the men were done smoking; -CNA A asked the other aide if he/she would monitor the few men who were still smoking; -CNA A came back inside to continue with his/her other duties. During an interview on 02/14/13 at 4:30 P.M. CMT D said the following: -Went to give Resident #1 his/her medications at 8:45 P.M.; -Resident was not in his/her room or bathroom; -CMT D and others searched other resident rooms and couldn't find Resident #1; -LPN A was alerted that Resident #1 was missing; -A Code White (procedure for elopement) was called; -CMT D and others searched all the resident rooms again and still did not find Resident #1. During an interview on 02/14/13 at 11:25 A.M. Licensed Practical Nurse (LPN) A said the following: -Shortly after 6:00 P.M. there was a resident to resident altercation in the outside smoking area; -Resident #2 hit Resident #3 on the chin with a closed fist; -Both resident were brought inside and assessed; -Resident #2 was still agitated and a code green was called; -Code Green was cleared and Resident #2 was placed on one to one monitoring; -He/She overlooked doing hourly checks for Resident #1; -CNA's had a sheet for residents on thirty minute checks and it was filled out for the evening of 02/12/13 by CNA B; -He/She knew that Resident #1 had a history of [REDACTED]. -We do not have enough staff at station two for the acuity of the residents. Review of a written statement dated 02/14/13 showed LPN A said the following: -On 02/12/13, at approximately 6:45 P.M., he/she was summoned to the station II outside smoke area because of an altercation between two residents; -He/she called a code green; -It took him/her until approximately 7:45 P.M. to complete the phone calls, assessments, and follow through with the resident to resident altercation; -At approximately 8:45 P.M., CMT D reported he/she could not find Resident #1 to give the resident his/her bedtime medication; -LPN A instructed staff to begin a room to room search of the entire unit; -Staff were unable to locate the resident; -At 9:20 P.M., LPN A contacted the DON; -The DON instructed him/her to call a code white and begin an outside search of the facility; -The station II courtyard was open; -LPN A instructed staff to close and secure the gate; -At 9:31 P.M., he/she received a call from the DON saying the resident had been seen on the facility grounds and to be prepared for the resident's return; -At 9:50 P.M., he/she received a call from the ADON to contact the facility's psychiatrist and obtain an order for [REDACTED]. -He/she received the order for the injection upon the resident's return if needed; -At 10:10 P.M., the resident was escorted to the focus room by staff and law enforcement; -Before entering the focus room, the resident became verbally and physically aggressive; -The injection was given and the resident was escorted by staff with law enforcement standing by; -Because of the resident's continued physical aggression, a five man take down was utilized; -At 10:20 P.M., due to the resident's continued aggression, LPN A contacted the psychiatrist again and received another order for Ativan 2 mg/Haldol 5 mg injection as well as an order to discharge the resident to an area psychiatric hospital for evaluation and treatment; -At 10:35 P.M., the resident was assisted to the transportation van and taken to the hospital. Review of a written statement dated 02/14/13 showed LPN/RCC (Resident Care Coordinator) E said the following: -On 02/12/13, he/she received a phone call at 9:21 P.M. from the DON stating staff could not locate the resident; -The DON told LPN/RCC E to drive around looking for the resident; -When he/she drove past the facility, he/she saw the resident walking toward the facility; -The resident had a glass bottle in his/her hand; -He/she slowed down and asked the resident if he/she was okay; -The resident said he/she was; -LPN/RCC E (still in his/her vehicle) followed the resident to the facility parking lot; -LPN/RCC E asked the resident to come in the building; -The resident started walking with him/her toward the door, then turned and began walking down the sidewalk; -LPN/RCC E opened the facility door and told staff the resident was outside; -The resident tired to get into the back gate which was locked at that time, and LPN/RCC E lost sight of the resident; -LPN/RCC E contacted the DON who instructed him/her to contact 911 for assistance; -When LPN/RCC E went around the front of the building, a police officer was pulling into the driveway; -LPN/RCC E told the police officer a staff member said the resident was on a residential street and staff was with him/her; -SSD H texted LPN/RCC E at 9:43 P.M., saying to send the police because the resident had a glass bottle; -LPN/RCC E called 911 back and told the dispatcher where the resident was; -The dispatcher said the officer was on his/her way; -Prior to police arriving, LPN/RCC E received another text saying the resident was threatening and running after staff; -At 9:45 P.M., SSD H called LPN/RCC E and reported the location of the resident, staff, and police; -The ADON arrived at the facility; -LPN/RCC E got in with the ADON and another staff member and drove to the scene; -The resident was face down on the ground; -The resident was cursing and spitting; -The resident pulled a bottle of beer from his/her pocket, drank it, and tossed the bottle on the ground; -The resident had already been maced prior to LPN/RCC E's arrival; -The officer hand cuffed the resident's wrists and ankles; -The officer reported he/she maced the resident because the resident threatened the officer and threw the first bottle at him/her; -The officers put the resident in the back of the police car and brought the resident back to the facility; -an order for [REDACTED]. -The resident was escorted to the focus room where he/she was threatening, spitting and kicking staff; -CALM (crisis alleviation lessons and methods) (five person take down) was used. Review of a written statement dated 02/12/13 showed SSD H said the following: -He/she received a call from LPN/RCC E on 02/12/13 at 9:28 P.M. stating the facility had a code white involving the resident; -SSD H responded to the facility at approximately 9:35 P.M.; -He/she got out of his/her car and saw the resident walking down the street; -SSD H met up with CNA G in the parking lot; -Both proceeded to follow the resident on foot; -SSD H attempted to redirect the resident; -When the resident turned around, he/she noticed the resident had a glass bottle in his/her hand; -The resident was very agitated and asked staff to leave him/her alone; -The resident was not redirectable and continued to walk several blocks; -The resident told staff to leave him/her alone or he/she would knock their head's off; -Staff continued to walk a safe distance behind the resident; -While walking, SSD H continued trying to speak with the resident; -The resident turned and charged after staff; -He/she once again told the resident staff were not trying to take him/her back to the facility, staff just wanted to make sure the resident got where he/she was going safely; -The resident took off running away from staff; -Staff ran behind the resident; -Staff met up with the police; -The officer tried to approach the resident; -The resident charged after the officer, then kept walking away; -The officer requested additional back up; -The officer and staff continued to follow the resident on foot; -The resident charged after them again, this time not stopping forcing the officer to use pepper spray to keep the resident from assaulting them; -The officer asked SSD H to call 911 and request additional back up along with an ambulance; -Additional law enforcement arrived; -When the additional officer arrived, the resident threw the glass bottle at the officer; -Law enforcement lowered the resident to the ground; -The resident repeatedly attempted to get up, so the resident was hand cuffed by law enforcement; -The ambulance arrived on the scene and flushed the resident's eyes; -Staff returned to the facility to round up available staff to assist with preparing for the resident's return to the facility; -Law enforcement escorted the resident to the facility as well as the focus room; -The resident immediately started resisting and became verbally aggressive; -The resident kicked a staff member in the stomach and spit on the staff member; -Staff proceeded to put the resident in a five man hold; -The resident continued to spit on staff and tried to head butt staff; -Staff lowered the resident to the floor and held him/her there until transportation arrived. Observation of the outside smoking area, where Resident #1 left from, showed the following: -Fenced in area with an unlocked gate; -Beyond the gate was an open field. Review of the local Police Department report showed the following: -On 02/12/13 at approximately 9:39 P.M., Officer A was dispatched to the facility; -Officer A observed the resident walking east with two nurse's aides; -Officer A stopped and made contact with the resident; -The resident was holding a glass bottle in his/her hand which he/she emptied onto the ground; -Resident #1 began walking toward Officer A, yelling that he/she was not going back; -Officer A pulled out his/her duty oleorsin capsicum (pepper) spray and told the resident to stop and backed up; -The resident turned and continued to walk down the street; -Officer A followed the resident on foot; -The resident turned toward Officer A and raised the glass bottle again and started running toward the officer; -Officer A sprayed the resident with his/her oleorsin capsicum spray and told the resident to back up; -The resident turned and ran and was met by a Sheriff's Deputy; -The resident threw the glass bottle at the Sheriff's Deputy; -The the resident layed down in the grass at the street intersection; -The Chief of Police arrived on the scene and cuffed and shackled the resident; -The local ambulance service was called and treated the resident's eyes; -The resident was then transported back to the facility and turned over to the staff. During an interview on 2/13/13 at 4:00 P.M. Officer A said the following: -He/She got a call a little after 9:30 P.M. that a resident had escaped from the facility; -When he/she found the resident, the resident started to physically come at him/her with a beer bottle, he/she backed off and the resident continued to walk; -He/She followed the resident on foot; -The resident suddenly turned and started towards him/her with a beer bottle raised in an aggressive manner; -That is when he/she pepper sprayed the resident; -The resident took off running; -The deputy arrived; -The resident threw a beer bottle at him/her striking him/her in the neck with the bottle; -The resident stopped and layed down in the grass around the corner of street intersection; -The deputy cuffed and shackled the resident; -The paramedics were called, they washed the resident's eyes out; -The police transported the resident to the facility; -Staff gave the resident a shot outside the facility and he/she thought another shot when the resident got inside; -The resident was extremely combative and six to seven staff members held him/her down until the medicine kicked in. During an interview on 02/13/13 at 3:55 P.M. the Sheriff's Deputy said the following: -The sheriff's office got a call at 9:37 P.M. that a patient was missing; -The deputy got a radio call that an officer had found the resident; -The resident came at the officer and the officer maced the resident; -The resident was wearing jeans and a red hooded sweatshirt; -The resident walked away and the officer followed on foot along with two staff members; -He/She stopped the resident at an intersection at in a residential neighborhood, approximately 0.5 miles from the facility; -The resident had calmed down a little; -He/she had the resident sit down and the officer cuffed and shackled the resident's legs; -The ambulance was called; -The ambulance staff washed out the resident's eyes; -The resident was transported back to the facility in a patrol car; -When we got there staff gave Resident #1 a shot of something to calm him/her down; -Staff put the resident in an isolation room and gave the resident another shot; -The resident started to calm down enough to take the cuffs and shackles off; -He/She overheard some staff say they hadn't seen the resident since the 6:00 P.M. smoke break and nobody knew the resident was missing until 8:45 P.M. medication pass. During an interview on 2/13/13 at 1:15 P.M. the local Chief of Police said the following: -The police heard there was a disturbance at the facility during a smoke break earlier in the evening; -Two residents had a physical altercation and it was thought this was when the resident sneaked away; -Which would have been a few hours before police found the resident. -The resident was found on the street by two officers; -The resident was in possession of two beer bottles; -The resident became belligerent and threw one of the bottles at the officer hitting him/her in the back; -The resident was maced by the officer and an ambulance was called, the resident's eyes were washed out, he/she was handcuffed, legs were shackled, and was taken back to the facility. During an interview on 02/14/13 at 10:30 A.M. the Assistant Director of Nursing (ADON) said the following: -The resident was on one hour face checks by the nursing staff and thirty minute checks by the aides. -ADON and administrator decided to bring Resident #1 back to the facility, knowing he/she would be transferred to a hospital; -Police transporter resident back to facility; -Resident #1 was brought into facility through the back door, leading into 500 hall where the focus room is; -Resident was given as needed Haldol 5mg and Ativan 2mg intramuscularly before being escorted into facility by two male staff on either side of the resident; -Resident #1 was still very agitated, ADON approached resident to speak with him/her resident spit in ADON's face and kicked him/her; -ADON sent staff to check if resident was on a list stating he/she could not be taken down to the floor, he/she was not; -Five staff members took the resident to the floor; -Resident #1 was given a second injection of Haldol 5 mg and Ativan 2 mg, resident started to calm; -Handcuffs and shackles were taken off resident; -Resident #1 was held on the floor for approximately an hour, until the facility van and staff were prepared to transport the resident to the hospital; -Resident #1 was placed in a wheelchair and taken to the facility van were he/she was transported to St. Alexis hospital accompanied by three staff members and a driver. Interview on 02/14/13 at 10:00 A.M. showed the Vice President of Health Care Services said the following: -He/she went to the local convenience store and reviewed the video surveillance tape; -The tape showed the resident stealing beer out of the cooler; -Resident #1 had beer under both his/her arms and walked past the cashier and out the door. Interview on 02/14/13 at 1:15 P.M. showed the administrator said the following: -The resident had a history of [REDACTED]. -Administrator's expectation would be when staff took the residents out to smoke, staff would make sure the residents came back into the building and were accounted for. Interview on 3/5/13 at 11:15 A.M. showed the medical director said the following: -He/She would expect staff to keep the resident safe, whether that would be locking a door or doing 30 minute checks; -If the resident was on 30 minute or hourly checks he would expect the nursing staff to be doing those. Complaint # MO NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility began implementation of changes to the physical plant including securing gates from enclosed areas with locks as an interim measure until electromagnetic locks with key pads could be installed. The facility began reassessment of residents for elopement risk and inservicing of employees regarding elopement protocol and assessment, monitoring and accountability, and visual face checks. The facility also began implementation of a code response team to ensure adequate staffing levels were maintained during a code situation. The facility had not completed corrective actions including inservicing education, code response team and duties, resident assessments or permanent locking mechanisms for exterior spaces/gates. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on interview and record review the facility failed to provide nursing care to one resident, (Resident #1) a resident with [DIAGNOSES REDACTED]. The facility assessed the resident with low blood sugar on the three scheduled checks on two shifts, ([DATE], [DATE] and [DATE]), with no communication with the physician. Licensed staff failed to follow facility procedures on notification, and administered a long acting insulin without informing the physician of the resident's low blood sugar on [DATE]. On [DATE] licensed staff assessed the resident with a critically low blood sugar and unresponsive, licensed staff left the resident's room and completed 12 Accu checks (blood sugar testing), on twelve other residents and did not return to the resident for approximately 30 minutes. The licensed nurse left the unit to get another licensed nurse to assess and intervene. Within minutes of an additional nurse responding the resident was assessed with [REDACTED]. The resident expired after transport to the hospital. The census was 108. 1. Review of Resident #1's medical record showed the resident was readmitted to the facility on [DATE] from the hospital where he/she was treated for [REDACTED]. The addition of [MEDICATION NAME] long acting insulin was ordered on [DATE] while the resident was hospitalized . Review of the resident's physician orders [REDACTED].M.) and Accu checks (glucose assessment), after meals and at the hour of sleep with sliding scale insulin. The orders showed no signature from a physician or nurse signature verifying the orders from a physician. Review of the resident's record showed no interim plan of care for the resident after readmission on [DATE]. Review of the resident's medication administration record (MAR) dated [DATE] through [DATE] at 5:00 P.M. showed the following: -On [DATE] at 9:00 P.M. staff documented the resident's blood sugar was 52, (normal range for blood sugar is ,[DATE] milligrams per deciliter); -On [DATE] at 9:00 P.M. Licensed Practical Nurse (LPN) I initialed he/she gave 30 units of [MEDICATION NAME] in an intramuscular (IM) route. (normal route is subcutaneous when giving insulin); -On [DATE] at 12:00 P.M. staff documented the resident's blood sugar was 40. (with no documentation that physician was called); -On [DATE] at 12:00 P.M. Licensed Practical Nurse (LPN) I initialed he/she gave 10 units of [MEDICATION NAME]-R insulin IM route. (normal route is subcutaneous when giving insulin); -On [DATE] at 5:00 P.M. staff documented the resident's blood sugar was 47 (no documentation in the resident's record the physician was contacted). Interview on [DATE] at 11:20 P.M. showed LPN I said the following: -He/She worked on the unit as charge nurse for over one year; -He/She readmitted the resident from the hospital on [DATE]; -admission orders [REDACTED].M. on [DATE]; -He/She expected the physician to sign the orders on [DATE]; -He/She did not call the physician or physician on call to verify admission orders [REDACTED] -[MEDICATION NAME] (a long acting insulin) insulin should be given IM, then he/she corrected his/herself and said subcutaneous (sub-q); -Resident #1 had low blood sugars on [DATE] at "noon" and 5:00 P.M., he/she was able to get blood sugars in an acceptable range with oral glucose; -The resident's low blood sugars on [DATE] were not called to the physician; -On [DATE] at 6:00 A.M. he/she clocked in for duty, passed LPN C in the copy/conference room, and entered the unit. Review of the resident's medication administration record (MAR) dated [DATE] at 9:00 P.M. through [DATE] showed the following: -On [DATE] at 9:00 P.M. LPN C initialed he/she gave 30 units of [MEDICATION NAME] in an IM route, (normal route is subcutaneous when giving insulin); -On [DATE] at 6:00 A.M. staff documented the resident's blood sugar was "lo" (when the glucometer reads "lo" this indicates a blood sugar less than 20). Review of the resident's nurses' notes written by Licensed Practical Nurse (LPN) C dated [DATE] showed the following: -On [DATE] at 0130 (1:30 A.M.), no complaints, alert and oriented times two; -At 0530 (5:30 A.M.) the charge nurse took the resident's Accu check, meter read low (a low reading indicates a blood sugar less than 20, normal blood sugar range ,[DATE]), resident unresponsive, Accu check redone still read low. Went to the nurse's desk to pull chart to see what the resident could have. A certified nurse aid (CNA) came back to the charge nurse and said the resident was still unresponsive, the nurse went to Station I to get another charge nurse, (nurse writing note in charge of Station II). Both went into the resident's room, resident still unresponsive. Observation and review of the glucometer memory on [DATE] used by LPN C showed between the first Accu check reading of low and the reading of 27 (both readings assessed by LPN C for Resident #1), there were 12 other Accu checks completed. All the other Accu check readings in the memory were consistent and correlated with results documented in 12 other resident records (MAR's) for that morning that were documented and signed by LPN C on [DATE]. Review of the resident's nurses' notes written by Licensed Practical Nurse (LPN) C dated [DATE] showed the following: -At 0554 (5:54 A.M.) Station I charge nurse told Station II charge nurse to call EMS. Station II charge nurse called EMS and the physician to get an order to send the resident to the hospital. Started to go back to the resident's room when a certified medication technician (CMT) advised he/she needed to know the resident's code status and so went back to look at resident's chart. Both charge nurses started CPR. Emergency medical technician (EMT) arrived at that time, (no time noted). EMT's continued CPR upon leaving the facility with the resident. Review of the resident's nurses note dated [DATE] written by LPN D showed the following: -At 0630 (6:30 A.M.) at approximately 555 (5:55 A.M.), charge nurse Station II (LPN C) came to Station I to say he/she had an unresponsive resident in room [ROOM NUMBER]. The nurse assessed the resident as unresponsive. LPN C told LPN D the resident's last Accu check read low at about 0600 (6:00 A.M.). Advised LPN D to call EMS. At this time gave glucose 15 and re-did Accu check at 601 (6:01 A.M.), with blood sugar reading of 27. Resident was still unresponsive. At this time the resident stopped breathing, tried Ambu bag then gave two breaths manually, no pulse noted. Started CPR at 603 (6:03 A.M.). At 603 (6:03 A.M.) EMS entered the room and took over CPR. Review of a written statement dated [DATE] regarding events on [DATE] A.M. showed Certified Nurse Aide (CNA) G said the following: -At 5:00 A.M. or 5:10 A.M. LPN C asked for juice to give to the resident, he/she returned and gave the juice to the nurse; -At 5:15 A.M. the nurse asked him/her to give the resident the rest of the grape juice; -CNA G tried to give the juice but it didn't work, he/she then took the resident's vital signs, and went to report to the nurse; -CNA G reported the vital signs to LPN C, who was at the nurse's station; -LPN C got up from the desk and went into the resident's room. Interview on [DATE] at 9:04 A.M. with CNA G showed he/she said the following regarding the resident and events on [DATE]: -He/she was working on the 400 hall at 5:05 A.M. when LPN C asked for juice, he/she provided the nurse with two boxes from the nourishment refrigerator; -At about 5:08 A.M. he/she was in Resident #4's room (room nearby Resident #1's room), getting Resident #4 dressed when he/she heard LPN C yelling Resident #1's name loudly and repeatedly; -At about 5:15 A.M. LPN C knocked on Resident #3's door and requested CNA G give Resident #1 some juice, after he/she finished with Resident #3; -Minutes later he/she entered Resident #1's room, found no staff in room , the resident was unresponsive, he/she attempted to apply a cold wash cloth, rubbed the resident's chest, and called the resident's name loudly with no success; -He/She then took the resident's vital signs, and went looking for LPN C, who he/she found sitting at the nurses station desk "Staring off into space"; -He/She accompanied LPN C to the resident's room, with the resident still unresponsive, with additional attempts to arouse the resident; -LPN C exited the room, and minutes later CNA H arrived to the room, and in a few more minutes LPN D arrived; -CNA H and CNA G then rolled the resident, "straightened up" the resident, and when finished, observed the resident had stopped breathing; -Certified Medication Technician (CMT) F arrived, and LPN D instructed CNA H to get the crash cart; -After the crash cart arrived LPN D started CPR, with CMT F and CNA H assisting; -LPN C then arrived to the resident's room and EMS minutes later, a little past 6:00 A.M.; -He/She could not recall any if Accu-checks were completed on the resident; -He/She could not recall if staff gave any medication to the resident. Interview on [DATE] at 8:36 A.M. with CNA H showed he/she said the following regarding the resident and events on [DATE]: -He/She worked on the unit (time unknown) when CNA G informed CNA H that Resident #1 "Didn't look so good"; -Upon entering the room, LPN C left the room, and CNA G was standing over the unresponsive resident; -A few minutes later LPN D arrived and assessed the resident by shining a flashlight into the resident's eyes; -CNA G and CNA H proceeded to provide incontinence care to the resident, who had a large bowel movement; -After rolling the resident after incontinence care, CNA G observed the resident quit breathing; -He/She left to obtain the crash cart from the nurses station, and informed LPN C (who was sitting at the desk) that the resident was not breathing and to call 911; -He/She returned to the resident's room with the crash cart, assisted placing the resident on the backboard, and observed non colored drool from the resident's mouth; -He/She left the room to wait and assist EMS for entry into the facility. Interview on [DATE] at 1:47 P.M. with CMT F showed he/she said the following: -He/she was passing medications on the unit 600 hall at 5:45 A.M. when she noticed LPN C performing blood sugar testing (Accu-check) on Resident #3. -CNA G told him/her in the 400 hallway that Resident #1 was " Looking bad " when he/she entered the 400 hall to continue medication pass; -Upon entering the 400 hallway at approximately 6:05 A.M. he/she observed LPN C on the telephone sitting at the nurses station desk, when LPN D yelled from the 400 hallway to LPN C "blood sugar 27"; -The resident's room was near the end of the hall, farthest from the nurses station; -He/she went to the resident's room where LPN D, CNA H and CNA G were with the resident; -He/she observed LPN C run by the resident's room with a chart out of the unit; -LPN D instructed CNA H to obtain the emergency medical (crash) cart, and LPN D started giving mouth to mouth respirations to the resident; -He/She met CNA H in the hallway with the crash cart, and brought it into the room for LPN D, handed LPN D the Ambu-bag (self-re-inflating bag used during resuscitation); -He/She helped LPN D place the resident on the backboard, and was asked by LPN D to find the resident's nurse, LPN C, and obtain the resident's code status; -He/She found LPN C in the conference room (off the unit), informed the nurse that LPN D requested he/she return to the resident's room; -He/She finished making chart copies of the resident's record to send with EMS. Interview on [DATE] at 2:47 P.M. showed LPN C said the following: -He/she had been LPN for approximately one year; -The facility provided no training on emergency response; -It was reported by the off going nurse, LPN I, that the resident had been running low blood sugars [DATE]. -He/She could not recall the resident's blood sugar on the [DATE] check at 9:00 P.M., if [MEDICATION NAME] was held, or if the resident received an evening snack; -The incident with the resident made him/her feel "stressed out" , and he/she "could not think clearly"; -He/she was the person responsible for all 15 Accu-checks on the unit; -He/She could not recall when he/she took the resident's first Accu-check that read "low", -The resident was slow to respond with the first reading of low. (The nurse's notes written by LPN C the day of the incident note the resident as unresponsive); -LPN C did not know what "low" meant on the glucometer; -He/she would have given oral glucose 15 (a high glucose tube product for rapid absorption through oral mucous membranes) if he/she had known that a low reading meant a blood sugar below 20; -He/she had previously witnessed a reading on the glucometer he/she used with a reading of 38; -His/her practice would be to call a physician on blood sugars below 40 if he/she could not get the sugar reading up; -He/she left the "unconscious" resident with unlicensed staff to leave the unit to get help from another nurse on a nearby unit; -He/she left the "unconscious" resident with unlicensed staff to call the physician for orders, and to wait for a call back. Review of a facility acquired undated written statement showed LPN C said the following: -At 5:35 A.M. on [DATE] he/she took the resident's Accu check, read low, resident able to open eyes, rechecked still read low; -He/She called the CNA in the hall to get juice, touched resident's tongue with a straw, resident would not suck on a straw; -At 5:38 A.M. he/she instructed the CNA after he/she got the resident up to give him/her juice; - At 5:39 A.M. he/she went to the desk to pull the chart to see what the resident could have for his/her blood sugar; - At 5:42 A.M. CNA to desk said resident unresponsive at that time grabbed the glucometer and the medication record and went to the resident's room; - At 5:43 A.M. resident unresponsive; - At 5:44 A.M. went to the Station I desk (this unit is on the opposite end of the facility through a keypad locked door) to get the other charge nurse and explained the resident was unresponsive; - At 5:45 A.M. Station I nurse LPN D and LPN C went to the resident's room, got glucose 15 from the treatment cart and put it in the resident's cheek while the other nurse tried to move it around; - At 5:48 A.M. LPN D told LPN C to call 911. During interviews on [DATE] at 11:32 A.M., 2:30 P.M. and 7:10 P.M. the Director of Nurses (DON) said the following: -Each nursing station had a specified glucometer; -The meter identified and checked for memory (during the observation of the meter on [DATE]), was the meter used for Station I (by LPN C); -Only licensed staff completed Accu checks; -There were two licensed staff in the building at the time, LPN C on Station I and LPN D on Station II; -Accu check results are recorded on the MAR; -Her investigation showed twelve blood sugars were completed and documented between Resident #1's low reading and the resident's later ready of 27, (some 30 minutes later). -She did not believe LPN C's account; - When she asked LPN C about the 12 blood sugars not included in his/her statement of what he/she had done that morning, LPN C said he/she might have missed some details; -The DON felt LPN C was lying to her in her investigation; -Her expectation was that with any blood sugar of 40 or lower staff should contact the physician; -Staff should not give juice to an unresponsive resident; -The resident expired the same day after transport to the hospital. During interview on [DATE] at 10:11 A.M. and 6:14 P.M. the administrator said the following: -Staff should not give liquids to an unresponsive resident; -Nurse's only do blood sugars on their units. Review of a letter from the resident's primary care physician dated [DATE] to the coroner showed the following: -The resident was admitted from the hospital to the facility on [DATE]; -The resident had several hypoglycemic (episodes of low blood sugar), events in the hospital, with insulin adjustments; -The resident had at least two hypoglycemic events at the facility requiring oral glucose; -He/She had no communication from the facility to address [DIAGNOSES REDACTED] after the resident's admission to the facility; -"The resident's death was a direct result of insulin dosing in conjunction with careless monitoring by facility staff". Interview on [DATE] at 1:10 P.M. with the resident's primary care physician showed he/she said the following: -He/She expected facility staff call the physician or physician on call to verify orders on an admission or readmission from the hospital; - Facility staff should call the physician or physician on call when a resident is hypoglycemic with a blood glucose less than sixty, so the physician would have an opportunity to make insulin dose adjustments; -A physician on call the weekend of [DATE] relayed no contact by facility regarding the resident's hypoglycemic events on [DATE]; - Routine insulin should be administered subcutaneously (SQ), (not intramuscularly). Interview on [DATE] at 1:22 P.M. with the physician on call for the primary care physician during the weekend of [DATE] showed he said the following: -The facility did not call to review orders with readmission of the resident; -He/She expected facility staff should call the physician or physician on call to verify orders on an admission or readmission to the facility from the hospital; -On [DATE] (could not recall exact time in the morning) the facility called reporting EMS was in route for a resident with a low blood sugar of 27; -He/She did not recall facility staff reporting any other low blood sugars. Review of the undated facility Glucose Monitoring policy showed: -In the event that a blood sugar is less than 60 the charge nurse will immediately be notified and the physician called; -After a blood sugar below 60, the charge nurse will continue to monitor for signs and symptoms of [DIAGNOSES REDACTED], and notify the physician for any decline in medical status. Review of the facility Emergency Procedure policy dated [DATE] showed the in the event a resident is found unresponsive or has had a significant change in their medical status the charge nurse will not leave the resident until a qualified person arrives. MO complaint #

Based on observation, interview and record review the facility failed to provide appropriate supervision for one resident, (Resident #2), who presented with a history of choking and taking food off other resident's trays of six sampled residents. The resident was to receive a mechanically altered diet, with ground meat and no bread. On [DATE] at approximately 3:00 P.M. staff brought the resident to the Station I nurse's desk in his/her wheelchair and positioned the resident next to the desk where staff had left a tray with a regular meal accessible to the resident. Staff observed the resident eating the food from the tray which included roast beef, baked potato and cake. Staff later witnessed the resident choking and intervened with the Heimlich maneuver. The resident was assessed with [REDACTED]. Staff contacted Emergency Medical Services (EMS) who arrived and intervened. The resident was pronounced dead at the facility. The census was 108. 1. Review of Resident #2's history and physical dated [DATE] showed the resident presented with [DIAGNOSES REDACTED]. Review of dietary progress notes dated [DATE] showed the staff documented the resident had many missing teeth and a tendency to choke on food. Review of the resident's swallowing recommendations signed by the speech therapist on [DATE] showed the following: -Observe for choking, coughing, pocketing food, gurgling or wet vocal quality; -Resident to remain upright 30 -60 degrees after meals; -Resident needs to empty mouth before next bite; -Alternate liquids and solids when eating; -Resident to eat slowly; -Position the resident at 90 degrees for eating; -Provide a mechanical soft diet with ground meat and a flow control cup. Review of the resident's care plan updated [DATE] showed the facility identified the following problems and approaches: -At risk for aspiration; -Remind the resident of swallowing precautions; -Resident takes others' food and drinks off peers' trays and needs to be redirected; -Provide a mechanical soft diet with no bread, use an adaptive flow controlled cup; -No bread, rolls, biscuits, croissants, muffins; -Bread products are a choke hazard; -Monitor the resident when eating; -Identified teeth in poor condition; -The resident had poor safety awareness, required tab alarm when in the wheelchair; -The resident had poor insight and judgment; -The resident had a difficult time making needs known due to aphasia (aphasia is a disorder caused by damage to the parts of the brain that control and limits effective communication). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff dated [DATE] showed staff assessed the resident as follows: -Did not use speech to communicate; -Sometimes was understood; -Responded to simple direct communication only; -The resident had short and long term memory problems; -Presented with cognitive impairment, with poor decision making abilities; -Felt it was very important to have snacks between meals; -Required extensive assistance of one staff for locomotion on the unit; -Required a mechanically altered diet with supervision and set up to eat; -The resident had a swallowing disorder. Review of the resident's speech therapy note dated [DATE] showed the following: -As a precaution the resident required supervision for safety during activities of daily living; -Resident required mechanical soft solids and thin liquids with a control flow cup or straw to reduce aspiration risk; -[DIAGNOSES REDACTED]. Review of the resident's progress note dated [DATE] showed the resident presented with [DIAGNOSES REDACTED]. Review of the resident's physician orders dated [DATE] through [DATE] showed the following: -Mechanical soft diet with ground meat, no concentrated sweets with a divided plate for meals; -Do not send bread with meals; -Aspiration, swallowing, and choking risk; -Adaptive plate and cup needed. Review of the staff monitoring sheets for the resident labeled "5 minute checks" on [DATE] showed: -At 2:45 P.M. the resident was in his/her room area; -At 3:00 P.M. the resident was in the dining room area; -No checks documented for 2:50 P.M. and 2:55 P.M. Review of the resident's nurses's notes on [DATE] written at 3:45 P.M. showed the following: -At 2:59 P.M. nurse was called stat to nurses station where a Certified Medication Technician (CMT) was performing the Heimlich maneuver on the resident who was in a wheelchair; -Observed the resident to have his/her jaw clenched shut; -Staff called EMS, and the unresponsive resident was lowered to the floor, where food was suctioned out appearing to be bread and potato; -Resident assessed to not be breathing, without a pulse, with EMS taking over care; -The resident expired in the facility. During interview on [DATE] at 4:45 P.M. CMT A said the following: -Last month he/she witnessed the resident independently walking to the staff break room for food; -The resident received a mechanical soft diet and guzzled liquids; -The resident choked easily and was on the aspiration precaution list; -On [DATE] at approximately 2:45 P.M. he/she brought the resident to the front of the nurse's station, locked the resident's wheelchair and left to find a nurse; -He/She was interrupted by another resident needing an as needed (PRN) medication on the hall; -He/She then returned to the nurse's desk and found the resident with his/her wheelchair unlocked pulled up to the nurse's station counter; -The resident was choking and flailing his/her arms and sliding down in the wheelchair; -He/She went behind the resident in an attempt to slide the resident back up into the chair when another certified nurse aide (CNA) B came; -He/She called for the nurse and started intervention for choking; -He/She got a creamy colored substance out of the resident's mouth which looked like mushy cake or potato; -He/She never saw a food tray at the nurse's desk because CNA A had just taken the tray to the kitchen; -He/She called a code overhead. During interview on [DATE] at 4:59 P.M. CNA B said the following regarding the resident on [DATE]: -He/She had worked at the facility for about two weeks; -The resident constantly grabbed and stole food from others and required distraction; -At about 3:00 P.M. she went to the nurse's desk and no staff were present; -He/She witnessed the resident "gobbling" food off a tray at the desk on the counter; -He/She removed the tray and took the tray into the kitchen; -He/She did not note the resident was in distress when he/she took the tray from the resident; -He/She could not recall if the resident was on special checks. Review of a written statement by CNA B on [DATE] showed he/she said the following: -The resident was known to "take food from other trays several times"; -He/She witnessed the incident, observed the resident by the counter "shoving" cake in his/her mouth; -He/She asked CNA J if the resident could have the food, was instructed by CNA J to remove the tray from the resident and take the tray to dietary; -Upon returning from dietary, he/she observed CMT A working with the resident who was choking; -Heimlich and emergency medical service (EMS) were provided, the resident expired in the facility. Interview with CNA J on [DATE] at 9:02 A.M. showed he/she said the following: -He/she worked at the facility for six years; -He/she frequently worked with Resident #2; -The resident was on a mechanical soft diet; -The resident was on frequent staff checks, could not recall why; -The resident was known for " woofing " food down fast; -The resident coughed a lot when eating too fast, he/she had never known the resident to choke; -He/she had previously witnessed the resident with a behavior of eating spilled foods from the floor; -On [DATE] around 3:00 P.M. he/she was at the nurses' station to obtain the restroom key when CNA B asked if the resident " is supposed to be eating that tray? " -Informed CNA B the resident should not be eating any food tray, and to remove the tray from the resident; -The resident was visualized at the side counter of the nurses' station, and could not visualize the tray; -The resident did not appear to be coughing or choking on the food; -Could not recall where the tray came from, or how long the tray was on the counter; -Then went to the administration hall to use the employee restroom for approximately three minutes, and upon return to the nurses' station observed CMT A performing the Heimlich maneuver on the resident; -He/she never visualized what type of food the resident choked on; -He/She was not involved in the emergency care of the resident, observed staff (unknown) pull unidentifiable food from the resident's throat; -The resident died in the facility. Review of the ambulance record trip information record dated [DATE] showed the following: -At 2:59 P.M. call received from the facility; -At 3:07 P.M. emergency medical staff on location at facility with the resident, with facility staff performing CPR upon arrival; -At 3:11 P.M. CPR discontinued per DNR wishes of the resident with residents death, with direction of hospital physician, contacted remotely by EMS personnel; -Large chunks of potatoes and cake found beside the resident. Interview with the dietary manager on [DATE] at 11:46 A.M. showed he said the following: -The lunch meal on [DATE] included roast beef with gravy, baked potato, cooked cabbage, fruit cobbler, and bread of choice; - The lunch meal substitutions on [DATE] included sliced turkey, mashed potatoes, and chocolate cake. Review of the facility provided written menu for dates of [DATE] thru [DATE] showed the following: -" Supper menu " for [DATE] was " stew, biscuit, and cookie " ; - " Supper alternate " [DATE] was " chicken and noodles " ; - " Lunch menu " [DATE] was " Roast beef, cabbage, baked potatoes, and cobbler/cake " ; - " Lunch alternate " [DATE] was " riblettes and turkey " . During interview on [DATE] at 3:55 P.M. and 7:10 P.M. the Director of Nurses (DON) said the following: -The resident was an aspiration risk and was impulsive; -The resident had dysphagia, and was aphasic; -The resident was known for stealing food from trays and was on five minute face checks; -The resident fed self but needed a flow controlled cup because he/she ate and drank too fast; -The resident was care planned for safety awareness including stealing food; -Food was a problem because residents left food in rooms, snacks on counters; -If staff observed a tray they should return it to dietary; -The resident was pronounced deceased at the facility by Emergency Medical Services in a conference call with the physician. During interview on [DATE] at 4:10 P.M. the administrator said the following: -The resident was on five minute face checks; -The meal tray the resident accessed and ate should not have been left at the nurse's desk, the tray should have been taken to dietary immediately; -Dietary should hand off snacks to nursing staff and not leave them at the desk; -Nineteen residents at Station I required a mechanical altered diet, Resident #2 was the only resident with eating behaviors the facility was aware of. Observation on [DATE] at 3:20 P.M. showed a tray of snacks including juice and cookies behind the Station I nurse's station on the counter and accessible to residents. No staff were located at the desk. Review of the facility policy Potential Aspiration Risk Residents undated showed the following: -Aspiration is considered foreign materials in trachea of lungs; -Symptoms of aspiration included coughing or difficulty breathing, change in the level of consciousness; To prevent risk of aspiration staff should ensure only the prescribed diet was provided to the resident; -Staff should assist in feeding and allowing resident adequate time for chewing and swallowing of foods. Review of the facility policy Mointoring of Residents undated showed the following: -Residents who require intensive monitoring due to behavior, or medical needs; -Residents with poor impulse control and behaviors may be placed on more intensive monitoring such as 5 minute or 15 minute face checks at the discretion of the administrative staff. Complaint # MO